KRAEPELIN Clinical Psychiatry PDF

CLINICAL PSYCHIATRY
CLINICAL PSYCHIATRY
FOR STUDENTS AND PHYSICIANS
ABSTRACTED AND ADAPTED FROM THE
SEVENTH GERMAN EDITION OF
KRAEPELIN'S "LEHRBUCH DEE PS YCHIATRIE "
BY
A.
ROSS DIEFENDORF, M.D.
LECTURER
IN
PSYCHIATRY IN YALE UNIVERSITY
MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, OF THE

NEW YORK NEUROLOGICAL ASSOCIATION, OF THE NEW YORK
PSYCHIATRICAL SOCIETY, AND OF THE AMERICAN
MEDICO-PSYCHOLOGICAL ASSOCIATION, ETC.
NEW
EDITION, REVISED
AND AUGMENTED
gorfc
THE MACMILLAN COMPANY

LONDON: MACMILLAN &
1915
All rights reserved
CO. LTD.
COPYRIGHT, 1902, 190T,
BY
Set
up and
THE MACMILLAN COMPANY.

Published May, 1902. Reprinted April, 1904.
August, 1912; March, 1915.
electrotyped.
ew edition, May,
1907
Norfooofi
J. 8.
Berwick & Smith Co.

Cashing & Co.
Norwood, Mass., U.S.A.
PREFACE TO THE FIRST EDITION

THE motive
for this
work was
to
make
the teachings
of Kraepelin in psychiatry accessible to American medical

students and general practitioners, and, at the same time,
to provide a full, but concise, text-book, not only for the
writer's
own
classes in psychiatry in the
Medical Depart-
ment
of Yale University, but as well for other American

teachers who follow Kraepelin's views.
Urged by the
rapidly increasing interest in Professor Kraepelin's teaching during the past five years in this country and the
constantly growing number of his disciples, it was the

writer's first intention to publish a complete translation
of the sixth edition of Kraepelin's " Lehrbuch der Psychiatric."
It was feared, however, that a full translation
would be too large to best subserve the function of a textbook, and would have rendered impossible the adaptation
of
the Kraepelin psychiatry to our peculiar American
heeds.
The classification, terminology, and, wherever possible,

the phraseology of this work are Kraepelinian, but the
writer has taken the liberty of abbreviating disproportionately the description of some psychoses which are of
less importance to the American physician, especially the
psychopathic states and thyroigenous insanity, and of laying more stress upon other more important forms, the description of acquired neurasthenia,
constitutional
traumatic neuroses, also the treatment in epileptic and

hysterical insanity
and acquired neurasthenia.
PREFACE TO THE FIRST EDITION
vi
The only omissions
are the general etiology, diagnosis,
in the first volume of Kraepelin, but such

of
are
most importance have been added to the
as
points
etiology, diagnosis, and treatment of the different diseases.
and treatment
The work has been done
in the pressure of
routine
as Assistant Physician and Pathologist of the

Connecticut Hospital for the Insane, and the writer begs
duties
leave to express in this place his grateful appreciation of

the generous advice and help of his colleagues in the
He is particuhospital, especially Dr. Charles W. Page.

larly indebted to Dr. J. M. Keniston for a general revision
of the text as well as for the arrangement of the chapter
on Epileptic Insanity, to Professor Raymond Dodge, Ph.D.,
of Wesleyan University, for criticism and suggestion with
regard to the general symptomatology, and to Dr. August
Hoch and Adolf Meyer for their continued inspiration and
critical assistance.
A.
MIDDLE-TOWN, CONNECTICUT,
January 16, 1902.
EOSS DIEFENDORF.
PREFACE TO THE SECOND EDITION

THE
favorable reception of the
first
editions of Clinical
Psychiatry and its constantly increasing use as a text-book

encouraged the writer to undertake a thorough revision
based on the seventh edition of Kraepelin's "Lehrbuch

In accord with the present views of
der Psychiatrie."
Professor Kraepelin there are introduced many important
changes, both in the general symptomatology and in the
For the condescription of the forms of mental disease.
venience of students the chapter on Methods of Examination is amplified by explicit practical suggestions adapted
to the circumstances under which most of them will be
compelled to work, while the more elaborate procedure of

the modern experimental laboratory has been omitted.
In response to a general demand, an abridgment of the
chapter on the Classification of Mental Diseases is added
to the present edition.
Less hampered by restrictions as
to size, the present edition follows more closely the context of the "Lehrbuch."
The description of the more
important forms of insanity is less curtailed, while the
psychogenic neuroses and the psychopathic states which

received scant attention are
tion.
now
given fuller consideraPersonalities did not
The chapter on Psychopathic
The writer has

make it clear by references wherever additions
own have been made. The most important addi-
appear in Kraepelin's earlier edition.

tried to
of his
tions without explicit references occur under the
Treatment.
vii
head of
PREFACE TO THE SECOND EDITION
viii
As
in the preparation of the first edition, the work has

been done under pressure of routine duties as Assistant
Physician and Pathologist of the Connecticut
Hospital
and the writer desires to express to his colappreciation of their help, and especially to
for the Insane,
leagues his
Dr. Henry S. Noble, Superintendent, his grateful obligation for placing at his disposal the time and much of the
material for the work.
Dr. J.
M. Keniston
He
is
under special obligations to
for help in reading proof
and the
arrangement of the chapter on Epileptic Insanity, and to

Professor Raymond Dodge, Ph.D., of Wesleyan University,
and suggestions with regard to the general

symptomatology and the Psychopathic Personalities.
for criticism
A.
MlDDLETOWN, CONNECTICUT,
April
6,
1907.
EOSS DIEFENDOKF.
CONTENTS
GENERAL SYMPTOMATOLOGY
PAGB
A. Disturbances of the Process of Perception

VHallucinations and illusions, perception phantasms, repercep.
tion,
double thought, apperceptive
nations, hallucinations
smell,
and
illusions, reflex halluci-
illusions of hearing, sight, taste,
and touch.
Clouding of Consciousness
Befogged states, disturbance of apprehension, retardation of
apprehension, diminished sensibility.
Disturbances of Attention
Active and passive attention, blocking of attention, dulling of
.
14
.18
attention, retardation of attention, blunting of attention,

passivity of attention, distractibility of attention, hyper-
......
prosexia.
B.
Disturbances of Mental Elaboration
23
Disturbances of memory, disturbances of the impressibility of

memory, disturbances of the retentiveness of memory, disturbances of the accuracy of memory, fabrication of memory.
Disturbances of orientation: time, place, and person disorientation; apathetic disorientation perplexity; delirious
disorientation amnesic disorientation delusional disorien;
tation.
Disturbances of the Formation of Ideas and Concepts

Disturbances of the Train of Thought
.
.,
.,
29
30
External association of ideas, internal association of ideas,

paralysis of thought, retardation of thought, compulsive
ideas, simple persistent ideas, perse veration, stereotypy, cir-
cumstantiality, flight of ideas, rambling thought, desultoriness.
.43
Disturbances of Imagination
.
.
Simple sluggishness, retardation, indifference, excitation of
the imagination, heightened suggestibility, autosuggesti.
bility.
Disturbances of Judgment and Reasoning
Knowledge and
belief, delusions,
ix
systematized delusions, delu-
47
CONTENTS
sions of self-depreciation, delusions of poverty, nihilistic
delusions, delusions of persecution, delusions of jealousy,
hypochondriacal delusions, delusions of self-aggrandize-
ment, delusions of mental soundness (absence of insight),
.....
....
......
expansive delusions.
Disturbances of the Rapidity of Thought
Retardation, acceleration.
Disturbances of Capacity for Mental Work
Disturbances of Self-consciousness
Dual personality, double consciousness, falsifications of
consciousness.
C.
56
57
58
self-
........
...
....... .65
..........
......
Disturbances of the Emotions

Diminution and Increase of Emotional Irritability
62
62
Emotional deterioration, temporary increase of emotional

irritability, change of mood.
Morbid Temperaments
Increased susceptibility to the unpleasant, apprehensiveness,

irritable
dispositions,
morbid
Morbid Emotions
fanaticism,
seclusiveness,
sunny
dispositions,
frivolity.
68
Fear, compulsive fears, phobias, dejection, sadness with ex-
citement, morbid feeling of pleasure, wanton happiness,

drunkards' humor, feeling of well-being.
Disturbances of General Feelings

Ennui, fatigue, hunger, nausea, pain, feeling of shame, sexual
indifference, increase of the sexual excitability, perverted
sexual feelings.
......
......
.......
D. Disturbance of Volition and Action

Diminution of Volitional Impulses
Paralysis of the will.
Increase of Volitional Impulse
....
Motor excitement, pressure of activity, busyness.

Impeded Release of the Volitional Impulse
Psychomotor retardation, stupor, blocking of the
tension.
Facilitated Release of Volitional Impulses

Distractibility of the will.
Heightened Susceptibility of the Will
73
77
77
78
79
will, rigid
.....
.....
81
83
Weakness
of will, hypersuggestibility, catalepsy, cerea flexibilitas, echopraxia, echolalia, distractibility of the will.
Interference and Stereotypy
.......
Crossing of voluntary impulses, stereotypy, mannerisms, superfluous embellishment, derailment of will.
84
CONTENTS
xi
PAGK
Diminished Susceptibility of the Will

Negativism, mutism.
Compulsive Acts
Impulsive Acts
88
Morbid Impulses
91
..........
..........
........
.....
Contrary sexual instincts, sadism, masochism, fetichism, kleptomania, pyromania.

Disturbances of Expression
Conduct arising from a Morbid Basis
Methods of Examination
Family
90
90
93
95
97
history, personal history,
anamnesis of the
disease,
status prsesens, disturbances of perception, clouding of consciousness, disturbances of apprehension, disturbances of

attention, disturbances of memory, orientation, train of
thought, judgment, emotional
field,
volitional field.
FORMS OF MENTAL DISEASES

Classification of
115
Mental Diseases
Consideration of the Factors entering into a Provisional Classi-
115
fication
I.
121
Infection Psychoses
A. Fever Delirium
Etiology.
Course.
B.
121
Symptomatology.
Pathological anatomy.
Prognosis.
Treatment.
125
Infection Deliria
Infection
typhoid, of smallpox.
delirium of malaria. Delirium of chorea. Deliria
Initial
of
deliria
of influenza, hydrophobia,
and
Acute
septic states.
delirium.
C.
131
Post-infection Psychoses
Mild Form.
Second group.
Severe form.
pathia psychica toxamica.

II.
Exhaustion Psychoses
A. Collapse Delirium
.
Etiology.
Course.
Diagnosis.
'
Pathological anatomy.
Prognosis.
Cerebro-
136
.
.
...
VT*,
.
B. Acute Confusional Insanity (Amentia)
Course.
Diagnosis.
Symptomatology.
Etiology.
Prognosis. Treatment.
C. Acquired Neurasthenia (Chronic Nervous Exhaustion) .
.
Etiology.
Course.
Symptomatology.
Diagnosis.
symptoms.
Treatment.
Physical
Prognosis.
137
Symptomatology.
Treatment.
141
146
CONTENTS
xii
PAGE
III.
Intoxication Psychoses
1. Acute Intoxications
Ptomaines.
2.
........
Chloroform.
159
159
Hasheesh.
Santonin.
Saturninia.
Encephalopathia.
Chronic Intoxication
A. Alcoholism
Acute Alcoholic Intoxication pathological and
anatomical findings
Chronic Alcoholism etiology, pathological anatomy, symptomatology, prognosis, diagnosis,
treatment
Delirium Tremens: etiology, pathological anat-
162
162
162
omy,
symptomatology,
diagnosis,
prognosis,
172
treatment
Korssakow's
Psychosis
etiology,
anatomy, symptomatology,
treatment
Acute Alcoholic Hallucinosis
pathological
course,
diagnosis,
183
etiology, symptoma-
tology, course, diagnosis, prognosis, treatment

Alcoholic Hallucinatory Dementia: symptomatology, course, diagnosis
Paranoia: symptomatology,
diagnosis, treatment
Alcoholic
.....
........
Alcoholic Pseudoparesis
Morphinism
Etiology.
Pathological
Anatomy.
Prognosis.
IV.
Cocain
Intoxication.
Etiology.
201
202
209
Hallucinosis.
........
Symptomatology.
Course.
214
214
Treatment.
216
Cretinism
Etiology.
197
200
Treatment.
Thyroigenous Psychoses
A. Myxoedematous Insanity
B.
195
Acute Mor-
Chronic Intoxication.
phine Intoxication.
Course.
Abstinence Symptoms.
Diagnosis.
Treatment.
Prognosis.
C. Cocainism
Etiology. Acute Cocain Intoxication. Chronic
Cocain
189
course,
Alcoholic Paresis
J5.
165
Pathological Anatomy.
Symptomatology.
Treatment.
V.
Dementia Praecox
Etiology
219
219
Pathology
221
CONTENTS
xiii
General Symptomatology: disturbances of apprehension,

disturbances of orientation, hallucinations, disturbance
of consciousness, disturbance of attention, disturbance
of memory, disturbance of the train of thought, dis-
turbance of judgment, disturbance of the emotional

field, disturbances in the volitional field
.
Symptoms
Hebephrenic Form: symptomatology,
Physical
physical symptoms,
230
course
Catatonic
222
229
Form:
pathological anatomy,
physical symptoms, course
symptomatology,
241
Paranoid Forms
Dementia Paranoides: symptomatology, physical symp:
toms, course
.........
....
Second Group symptomatology, course

Diagnosis of Dementia Prsecox
Treatment of Dementia Prsecox
:
VL
260
265
272
Dementia Paralytica
276
Etiology (juvenile paresis)

.
Anatomy
General Symptomatology
276
279
280
Pathology
Pathological
257
disturbances of apprehension,
disturbances of memory, disturbances of the train of
:
thought, disturbances of judgment, disturbances of the

.
.
.
.
.
.
emotions, conduct
.
285
Physical Symptoms sensory symptoms, paralytic attacks,

disturbances of speech, ataxia, reflexes, vasomotor dis:
turbances
Demented Form
Expansive Form (megalomania)
Form (galloping
Depressed Form
Agitated
......
.
301
307
paresis)
310
Course of Dementia Paralytica

Diagnosis of Dementia Paralytica
314
315
318
Prognosis (arrested paresis)
VH.
290
299
319
Treatment
Organic Dementias
323
Gliosis of Cortex (diffused cerebral sclerosis)
......
323
Huntingdon's Chorea: physical symptoms, course, diagnosis, pathological anatomy

Multiple Sclerosis
Cerebral Syphilis: simple syphilitic dementia, syphilitic
pseudoparesis
323
326
326
CONTENTS
xiv
PAGB
Tabetic Psychoses
332
Arteriosclerotic Insanity: pathological anatomy, symptomatology, severe progressive form, diagnosis, treatment
333
Cerebral
Tumor
341
343
Brain Abscess
Cerebral Apoplexy
Cerebral Trauma traumatic delirium, traumatic dementia
Involution Psychoses
:
VIII.
A. Melancholia
343
344
348
348
Etiology. Pathological anatomy. Symptomatology

delusions of self-accusation, hypochondriacal delu-
hallucinations,
sions,
disturbances
of
nihilistic delusions.
Physical symptoms.
Prognosis. Treatment.
.....
Diagnosis.
Presenile Delusional Insanity
B.
Symptomatology.
nosis.
Treatment.
C. Senile Dementia
Etiology.
thought,
Course.
Diagnosis.
364
Prog-
369
Pathological anatomy. Symptomatology.

Physical symptoms. Severer grade of senile deSenile Delirium. Sementia.
Presbyophrenia.
Etiology.
.......
nile Delusional Insanity.
IX.
Manic-depressive Insanity
Treatment.
Diagnosis.
381
381
Etiology
Symptomatology: disturbances
of apprehension, disturbances of perception, disturbances of memory, disturbances of judgment, disturbances of thought, disturbances
of the emotional and volitional fields
....
Manic States
390
Delirious
390
symptomatology, physical symptoms, course
Hypomania
Mania (Tobsucht)
:
..........
course
symptomatology, physical symptoms,
Depressive States
symptomatology, course
symptomatology
physical symptoms, course
Simple Retardation
Delusional
Form
Stuporous States
States
Irascible mania.
Manic
Depressive excitement.
Unproductive
stupor. Depression with a flight of ideas.

Depressive state with flight of ideas and emotional ela-
mania.
tion.
394
Mania: symptomatology, physical symptoms,
course
Mixed
382
397
400
400
402
405
407
CONTENTS
Course
xv
......
..........
of
Manic-depressive
Insanity
lucid
duration,
intervals, transition states
..........
..........
...........
........
.........
Diagnosis
X.
Prognosis
417
Treatment
419
Paranoia
Etiology.
nosis.
Symptomatology.
Treatment.
Course.
423
Prog-
Diagnosis.
Querulent Insanity
XI.
412
415
Epileptic Insanity
432
434
Etiology. Pathology. Symptomatology. Physical sympPeriodical ill-humor.

toms.
Befogged states: preinsanity,
somnambulism,
deliria,
conscious
epileptic
delirium,
Treatment.
Prognosis.
XII.
post-epileptic
epileptic
epilepsy,
The Psychogenic Neuroses

A. Hysterical Insanity
insanity,
-psychic
stupor,
anxious
dipsomania.
Diagnosis.
.......
.......
driasis.
Symptomatology: hysterihypochonBefogged states

Physical symptoms.
delirious
states,
Etiology.
457
457
Pathology.
cal personality, changes in character,
hysterical lethargy,
lism, silly excitement.

nosis.
Treatment.
Course.
Diagnosis.
Traumatic Neurosis (traumatic hysteria)

Etiology. Symptomatology. Diagnosis.
Treatment.
C. Dread Neurosis
B.
Prog.
Course.
Constitutional Psychopathic States.

eracy.)
Diagnosis.
(Insanity of Degen-
Diagnosis.
485
485
Treatment.
492
Treatment.
Symptomatology. Diagnosis. Treatment.

D. Compulsive Insanity
Tormenting Ideas: onomatomania, arithmomania,
Griibelsucht, folie du doute, erythrophobia. Phobias
480
Treatment.
A. Nervousness
Symptomatology. Course.
B. Constitutional Despondency
Symptomatology. Course.
C. Constitutional Excitement
475
Prognosis.
........
..........
.........
......
......
.......
Symptomatology.
XIII.
somnambu-
agoraphobia, mysophobia, delire du toucher.
Crises. Impulsions. Course. Prognosis.
Treatment.
495
498
CONTENTS
xvi
PAGR
E. Impulsive Insanity
The impulse
F.
XIV.
XV.
to
507
tramp.
Pyromania.
Impulse to kill. Course.

Contrary Sexual Instincts
Etiology. Symptomatology.
Treatment.
Kleptomania.
Diagnosis. Treatment.
510
Diagnosis.
Psychopathic Personalities
A. Born criminals (moral insanity, "delinquente nato,"
moral imbecility).
Etiology.
Symptomatology.
Diagnosis. Treatment
B. The Unstable
Symptomatology. Diagnosis. Treatment.
C. The Morbid Liar and Swindler
Symptomatology. Prognosis. Treatment.
D. The Pseudoquerulants
Diagnosis. Treatment.
Defective Mental Development
A. Imbecility stupid form, lighter grades, energetic type.
Course. Diagnosis. Treatment
B. Idiocy
....
}/
Prognosis.
Etiology.
Pathology.
cases, light cases.
ment.
Symptomatology
Diagnosis.
Prognosis.
severe
Treat-
515
515
521
526
531
536
536
544
ILLUSTRATIONS
FACING PAGK
PLATE
1.
Muscular tension in catatonic stupor
246
PLATE
2.
Muscular tension in catatonic stupor
248
PLATE
3.
Cerea
250
FIG.
1.
Catatonic writing showing verbigeration
flexibilitas in catatonic stupor
....
251
PLATE
4.
Illustrates the normal pyramidal cell of the cerebral cortex
and the cytological changes occurring in dementia paralytica
.
282
5.
The normal cerebral cortex cerebral cortex in idiocy and
dementia paralytica also the glia in the normal cortex, the presence of spider cells in dementia paralytica and their relation with
PLATE
284
the blood-vessels
PLATE
6.
group of
paretics, illustrating the lack of expression in
the countenance and the inelastic attitude
294
PLATE
7.
Paretic handwriting
296
FIG.
1.
Paretic handwriting
296
FIG.
2.
Paretic handwriting showing partial agraphia
296
FIG.
3.
Paretic handwriting showing complete agraphia .
296
PLATE
8.
Paretic handwriting
298
PLATE
9.
Group of three cases of Huntingdon's chorea,
were trying to look at the photographer
PLATE
10.
Arteriosclerotic cortex
PLATE
11.
Self-decorated
PLATE
12
FIG.
1.
normal cortex
all of
whom
324
....
manic patient
334
396
398
398
Macrocephaly
FIG. 2.
Microcephaly.
FIG.
3.
Representing asymmetry of cranium and face
FIG. 4.
Representing asymmetry of cranium and face
398
398
.
398
A.
DISTURBANCES OF THE PROCESS OF

PERCEPTION
THE
perception of external sensory stimuli depends

two
conditions: the adequate stimulation of the
upon
sensory end organ and the elaboration of this stimulation
;
by the central nervous system.

The loss of one or more of the senses modifies mental
development in proportion to the importance of the sensory material lost and the possibility of substituting other
Loss of sight is relatively unimportant, but loss of hearing, on account of its relation to
sensory experience.
language, is of great importance indeed, unless specially

trained, deaf mutes remain mentally weak through life.
;
Illusions and Hallucinations.

More important than the
mere absence of sensory experience is its falsification.
Inadequate stimulation of the sense organ produces

"
of
impressions corresponding to the "specific energy
that sense for instance, an electric current may produce
a sound, a taste, a tactual or a visual sensation, according
;
as
it
stimulates the corresponding sense organ.
Such sen-
sations are real illusions, but they do no harm because

they are immediately recognized as illusions. In condi-
on the contrary, especially
tions of mental disturbance,
is great clouding of consciousness, the subsensations

of light as the result of congestion of
jective
where there
the eye, or a roaring in the ear, may be interpreted as

or torrents of water, giving rise to genuine deceptions
fire
which are not corrected.
This sort of peripherally conditioned sense deception has been called elementary, on
account of its origin in that part of the sensory apparatus
which receives the stimulus.
States of consciousness similar to sensory perceptions
may be produced by the excitation of the so-called cortical
naturally referred to an external

object, and results in an illusion as to the real source
of the stimulus.
This group of hallucinations may be
sensory areas.
This
is
called perception phantasms.
They may occur
in
normal
individuals, particularly at the onset of sleep, as hypnogogic hallucinations. In abnormal conditions, they are
extremely vivid and misleading. They usually

bear no relation to the content of thought, and, conseoften
quently, seem to the patient to belong to the external

world. They have a fairly uniform content, subject only
to slight modification (stable hallucinations of Kahlbaum),
and consist of senseless words, noises, figures, and the like,

which are repeated over and over again. Because of their
central origin, they
may
occur after destruction both of
the peripheral sense organ and the afferent nerve. The

cases of hemilateral disturbance of the field of vision, in
which the gaps produced by the disordered perception are

out by the patient, point clearly to central origin in
that portion of the cortex which has to do with visual
filled
perception. There are some cases in which sense deceptions have prevailed in the normal half of the field of
vision, where the cortex in both occipital lobes has been
diseased.
Again, coincident with the rapid development

been observed
of the bilateral cortical blindness there has
sudden development
of active perception of light.
DISTURBANCES OF THE PROCESS OF PERCEPTION
Peripheral influences may also produce, directly or indirectly, conditions of excitation in the higher portions of
the sensory tracts, which lead to sense deceptions, particuthe general irritability of these parts is increased.
In morbid conditions, ordinary organic stimuli suffice to
larly
if
produce such falsification. In other cases, these hallucinations may appear if attention is merely directed to that
sensory field, or if an emotional condition temporarily
increases the general susceptibility to stimulation.
It
disappears, on the other hand, as soon as the patient
becomes quiet or directs

conversation,
his attention elsewhere, as in
manual or mental employment, change
Further evidence of cooperation of

conditions of stimulation in the sense organ is found in
the occasional occurrence of one-sided hallucinations, the
of environment, etc.
frequent association of chronic middle ear disease with

hallucinations of long standing, and the production of
hallucinations of sight in alcoholic delirium by gentle
pressure on the eyeball. Usually these sense deceptions appear only in a single sensory field, and are
frequent in the fields of hearing and sight.
most
Sense deceptions are divided clinically into hallucinations
and
nizable
illusions.
In
real percepts.
In some
the
former there are no recog-
are falsifications of
cases this distinction may be dif-
external stimuli;
the
latter
carry out on account of internal stimulation of

the sense organs, such as occurs in phosphenes, entotic
ficult to
noises, etc.
In other cases the distinction
is clear.
The
perception of ghosts in moving clouds and limbs of trees,

curses and threats in ringing bells, are evidently illusions.
But the well-known visual disturbance of the alcoholic,
and the voices which torture the condemned
when everything
is
in his prison,
quiet, are pure hallucinations.
The universal
is
deceptions
characteristic of the entire group of sense
their sensory vividness.
They depend on the
same sort of cerebral processes as does normal perception,

and the false perception takes its place in consciousness
among the normal sensory impressions without any disThe patients do not merely
tinguishing characteristic.
believe that they see, hear, and feel, but they really see,
hear, and feel.
In morbid conditions very vivid ideas or memory images
may assume the form of hallucinations, being regarded by
the patients as real perceptions of a peculiar kind. Many
investigators hold that all false perceptions should be
regarded as ideas of imagination of extraordinary sensory
But
vividness.
in order that
an idea attain the
clearness
This
special cause must be present.
is indicated by the fact that in patients suffering from
hallucinations, not all, but only certain groups of ideas
of a perception,
some
seem to play a role in the sense deceptions, and besides these

there are usually ideas of the ordinary, faded, and formless
The element which makes a hallucination out of
type.
a vivid idea
probably a reflex excitation of those censensory tracts, through which alone normal stimuli
tral
come
to
is
consciousness
(the so-called
"reperception" of
If it is really these areas of the brain through

Kahlbaum)
whose excitation perception acquires its peculiar sensory
.
marks,
it is
easy to see
how they may
ing degrees in the active process of

sions.
lies
participate in vary-
renewing previous impres-
A view of this sort would explain the fact that
there
between the sense deception of pronounced sensory vividand the most faded memory image an unbroken series
ness
of transition stages.
thought processes
It is possible that during the ordinary

this reflex excitation or reperception
is
always present in a very slight degree, but that only when
the process becomes morbid, or the sensory areas themselves

are in a condition of increased excitability, does the vividness
of the
tion.
picture approach that of true sense percepProbably there is, moreover, a definite relation be-
memory
tween the strength of the reperception and the
irritability
the greater their irritability, the more

easily will the memory images attain sensory vividness, the
lighter the reflex excitation need be to release them, and the
of the sensory areas
more independent they are of the current of thought. The

extreme case would be found in the sense deceptions depending upon local excitation, which seem to the patient to be
something quite foreign and external. The extreme case
in the other direction would be those instances which are
not true sense deceptions at
all,
but merely ideas of great
sensory vividness. By careful investigation it is often posanalyze the data given by the patient, which apparently indicated hallucinations, and to discover that the pa-
sible to
tient does not regard the impression as objectively real,
merely differentiates
it
is
his ordinary ideas on account

In these cases it is probable that
from
of its forceful vividness.
the reperception
but
strongly developed, while irritability of

This seems to be
is not increased.
special sensory tracts
borne out by the fact that this group of hallucinations, which

has been variously designated as psychic hallucinations
(Baillarger), pseudohallucinations (Hagen),
and apprehen-
sion hallucinations (Kahlbaum), involves several or all of

the sensory fields, and that it always stands in close relation
to the other contents of consciousness
fications of perception,
a single sensory tract,
while the true
falsi-
on the other hand, usually belong to

and are independent of the train of
thought.
A striking illustration of this type of hallucinations is

found in a condition called "double thought." Immediately
any idea, the patient has another distinctly subsequent idea of the same thing i.e. every idea
This double
is followed by a distinct sensory after-image.
thought occurs most frequently when the patients are reading, sometimes when writing, and occasionally, also, when
The sensory
linguistic ideas come vividly to consciousness.
if
the
are
words
after-image disappears
actually spoken.
upon the appearance
of
Other hallucinations of hearing universally accompany
this
condition.
Apperceptive illusions are those in which subjective elements unite with the objective sensory data, giving rise to a
distorted and falsified impression.
They are of very fre-
quent occurrence in normal life prejudice, expectation, and

the emotions continually influence our perceptions even in
Even the most transpite of our earnest effort to be neutral.
;
quil scientific observer is never quite certain that his per-
ceptions do not unconsciously suit themselves to the views

with which he approaches his investigation while in reading
;
we
unconsciously correct the errors of the type-setter

from the residua of our experience. In mental disturball
ances the conditions are often extraordinarily favorable

Marked emotional
for this falsification of apprehension.
excitement, great activity of the imagination, and finally,

the inability to sift and correct experience by reason,
all
are favorable to its development. Thus, it frequently hap-
pens that the sensory impressions of patients take on fantastic forms and become the basis of a thoroughly falsified
apprehension of the external world, even when there are
no true hallucinations. This phenomenon naturally occurs

most frequently, both in normal and abnormal states, when
the sensory impressions are confused and indefinite, and not
readily differentiated.
There
is
an
allied
group of disturbances which consists

in the release of a false perception in
one sensory
field
through a real impression received by another, constitut-
ing the so-called "reflex hallucinations of Kahlbaum."

sensory stimulus may produce conditions of excitation,
which, transferred to an over-excited sensory area, occasion

the development of an hallucination. Similar conditions
are daily encountered in the so-called sympathetic sensations, like the unpleasant sensation of an inexperienced onlooker at a painful surgical operation. In morbid conditions these may be very marked.
Especially sensations of
movement which
frequently
accompany sense impressions
seem
way. There are patients who feel on
their tongues the words spoken by others; a glance from
some one may excite a sensation of strain.
to rise in this
very important characteristic of sense deceptions,

in one way points to their origin and in another to
which
symptom, is the powerful and

which they exert over the entire thought
their importance as a disease

irresistible influence
and
activity of the patient.
It is true that occasionally
sound and,
pronounced
also, that at the beginning, as well as at the end, of a mental
illusion
appears in persons mentally
disease the illusions are often recognized as such, because of

their improbable content, but usually persistent illusions and
hallucinations overpower the judgment, and ultimately the

patients invent the most foolish and fantastic explanations
to account for them.
The
basis for this irresistible influence
is
not to be found
in the sensory vividness of the illusion, since real sensa-
tions
and
definite evidence are useless as correctives.
Its
explanation is found rather in the intimate connection between the illusions and the patient's innermost thought, morbid
and desires. The emotional states and the feelings

color the illusions in a peculiarly high degree, as one might
fears,
10
expect from their influence in normal life. It is frequently

observed, especially in the end stages of dementia praecox,
that illusions appear only in connection with the periodical
vacillations of the emotional state, while they completely
disappear in the interval. This influence of the emotional
upon the thought and actions only disappears with recovery, or when progressive deterioration obliterates emo-
life
tional activity.
In both cases the illusions
may
continue,
but the patients do not react upon them.

These facts manifestly disprove the general view that
sense deceptions regularly, or even frequently, act as the
causes of delusions. To be sure, patients point to
their hallucinations as the basis of their symptoms, but
real
there can be no doubt that the sense deceptions have a

common source of origin with the other disturbances of the
In reality the patient's attitude toward

his illusions and hallucinations is not the same as his attimental equilibrium.
tude toward his actual perceptions. No healthy individual

would refer to himself such words as "That is the president,"
and then immediately believe he must be the president.

But when these words form the keystone of a long chain of
secret misgivings, an hallucination of that sort makes the
most profound impression, and immediately there arises a
firm conviction, not only that the words were really spoken,
but that they express the truth.
In view of these facts we see no special practical value
in distinguishing in single cases whether the delusion, the
emotional state, or the corresponding sense deceptions
appear first. In the vast majority of cases, and especially
where the sense deceptions appear with persistent delusions, all of these disease
result of
one and the same
Illusions
are certainly only the

cause.
symptoms
common
and hallucinations present a
large
number
of

clinical types in the different sensory fields.
The most
11
fre-
quent sense deceptions of sight are those which occur at

night, the so-called visions; God, angels, dead persons,
The less
distorted figures, wild animals, and the like.
common
sense deceptions of sight which appear in daylight along with the normal impressions are much more like
normal perceptions and consequently more deceptive.
The
sense deceptions of the alcoholics are of this type (see

The objects of the surroundings may take on an
p. 176).
entirely different appearance;
patients mistake strangers
for relatives and

versa, and believe that the same
persons are taking on different forms and faces, are making
vice
grimaces, etc.
The most important sense deceptions

so-called voices,
a term which
of hearing are the
usually well understood
by
The basis for their importance lies in the fundamental significance of language in our psychic life. The
is
the patient.
voices usually have
consciousness;
an intimate relation to the content
of the patient's inmost thought,

for
him a
of
in fact, they are the linguistic expressions
far greater convincing
and
for this reason
power than
all
have
other sense
deceptions, more even than real speech. The voices mock

the patient, threaten him, and tell his secrets. They are
heard in the scratching of a pen, in the barking of dogs, etc.
Sometimes there are several distinct "voices" with char-
Usually they are low, as if coming

from a distance, though occasionally they are loud enough to
drown all other noises. It rarely happens that the "voices"
speak long sentences. Usually they consist of short, in-
acteristic differences.
terrupted remarks. The hallucinations in fever delirium

and in greatly bewildered patients are changeable and confused.
Auditory sense deceptions are seldom indifferent to the
12
almost always accompanied by strong

emotional disturbances and wield a powerful influence over
the patients' actions. They make them distrustful, excited,
patients, but are
and even drive them
to angry attacks
on
their imaginary
tormentors.
The
so-called
"internal
phoning," "telegraphing,"
voices"
etc.,
"suggestions,"
"tele-
form a special group of
hallucinations of hearing. These naturally are not regarded

by the patients as sensory in their origin. They may occur
monologue or as a conversation with distant

persons; sometimes the voices of conscience seem to critias a kind of
the patient or spur him on. In all these cases the patient develops the delusion that his thoughts are known to
every one, or that they are produced and influenced by outcise
side forces.
Sense deceptions in the other senses are of much less

importance. False perceptions of taste, smell, dermal,
muscular, and general senses, so far as they derive their
the
origin from the thoughts of the patient, and not from
disturbance of the sense organs, point to a profound change
of the whole psychical personality.
Where
delusions of electrical influence, of position, of
incasement of different organs of the body, the disappearance of the ears, mouth, etc., are present we no longer have
simple illusions and hallucinations, but almost always a
severe disturbance of the higher psychical processes.
Hallucinations develop differently. One might judge
The type of the hallucination
this from their great variety.
be determined in a measure by the form of the mental

In fever delirium and infection psychoses the
disease.
may
hallucinations
and
illusions are variable
and dreamlike, ocand producing
curring in all the different fields of sensation
a most confused and fantastic experience.
Similar hallu-

cinations
and
illusions exist in the alcoholic delirium,
13
but
here they present a peculiar sensory vividness and they combine so that the separate experiences are much more defi-
Indeed, they combine so intimately with each other

that they offer a good foundation for the development of
"
an occupation delirium." Another characteristic of these
alcoholic hallucinations and illusions is that they are very
nite.
numerous and change rapidly. These sense deceptions,

originating as they do from imperfectly perceived impressions, can even be created and influenced by mere suggestion.
The hallucinations in cocainism which appear in the visual
and auditory fields and in the field of general sensibility
"
are closely related. The
microscopic" hallucinations of
the perception of
numerous minute objects, little animals, or holes in the wall
On the other hand in the epileptic delirium
or little points.
sight are particularly characteristic;
i.e.
the hallucinations are accompanied by a peculiarly intense

tone of feeling; for instance, the sight of blood, of fire,
objects of fear, the hearing of threats, the noise of shooting,
In all of these conditions it is

or the music of angels.
an
extensive involvement of the corprobable that there is
tex by the disease process. This seems the more probable
as clouding of consciousness regularly accompanies these
states.
Other disease processes present even more transiwith hallucinations involving the dif-
tory delirious states
such as manic-depressive insanity, senile

In
dementia
dementia,
praecox, and occasionally paresis.
the bewildered and excited stages of dementia praecox hal-
ferent senses:
lucinations of hearing predominate, while in similar states

in manic-depressive insanity hallucinations of sight are
more prominent, and particularly hallucinations of the general sensibility.
In paresis illusions are
much more
evident
than hallucinations, although both are comparatively
infre-
14
quent. There is only a small group of cases in which the

sense deceptions involve only a single sensation ; as, for instance, in
most cases
and
which
of acute alcoholic hallucinosis,
some
cases of alcoholic hallucinatory dementia, in

there are very striking hallucinations of hearing. Also in
some epileptic states, hallucinations of hearing only appear.
Hallucinations of hearing alone are by far most frequent in

dementia prsecox. They are rarely absent long. Usually
they represent one of the

tinue as the only
first
symptom
symptoms and often they consome time. In the delirious
for
states of dementia prsecox they are usually associated with
hallucinations
and
illusions of the other senses.
It
also in
is
dementia praecox that the peculiar disturbance called

"
The content of the haldouble thought" mostly occurs.
lucinations is of a fearful or disturbing nature only at the
beginning, while later it becomes more or less indifferent and
senseless,
which
is
in
marked contrast
to the other forms of
mental diseases mentioned above.

Clouding of Consciousness.
within us characteristic mental
External stimuli occasion
phenomena which we appre-
hend immediately and distinguish as presentations, feelThis experience is designated as conings, and volitions.
which
is present whenever physiological stimuli
sciousness,
are converted into psychic processes.
The nature
of con-
obscure, yet we know not only that it in gendepends upon the functioning of the cerebral cortex,
but also that its individual phenomena are connected with
definite, but as yet undetermined, physiological processes
sciousness
is
eral
in the
nervous system.
Just as the transition of the external
stimuli into sensory excitations depends upon the nature of

the sensory organ, so the condition of the cerebral cortex
is
the determining factor in the transformation of physiologiWhether such transformation
cal into conscious processes.

takes place in individual cases
mine, since
is
15
often very difficult to deterinsight into the inner
we have no immediate
experience of others and are compelled to draw our conclusions from their behavior.
The condition
in
which the transformation
of physio-
logical into psychical processes is completely suspended, is

designated unconsciousness. Every stimulus which crosses
the threshold of consciousness, thereby arousing a psychic

process, must possess a certain intensity which cannot sink
below a definite
limit.
This limit
is
called the threshold
value and varies greatly according to the condition of the

While it is lowest in strained attention, the threshcortex.
old value reaches infinity in the deepest coma. It is thus
possible to distinguish different degrees of the clearness of
consciousness according to the character of the threshold
But even when conscious processes are no longer

aroused by external stimuli, consciousness in the form
of obscure presentations and general feelings may still
value.
exist.
the clearness of consciousness decreases sufficiently,

befogged consciousness results (Dammerzustand) during
If
which neither the external nor internal stimuli can create

These befogged states are
clear and distinct presentations.
encountered in epileptic and hysterical insanities, as transitory states contrasting sharply with the normal life of the
Prolonged befogged states are also found in

mental
which
processes are rendered difficult and the
individual.
psychophysical threshold is considerably raised. Sometimes the threshold value may be so altered that it is different for external
and
external stimuli have
internal stimuli
that
is,
while
internal stimuli produce

This is what occurs in delirious
little effect,
vivid conscious processes.

The opposite condition obtains in
states.
demented
states,
16
where not infrequently external stimuli easily produce sensations, while internal have little effect in consciousness.
What occurs here is not an increase of the threshold value,
but a prolonged sinking of the psychophysical excitation.
Indeed, this is the distinction between dementia and the
befogged states.
Disturbance of Apprehension.
The full effect of an
external stimulus takes time.
Experiment demonstrates
that our sense perceptions reach the point of greatest clearness only after a period of
circumstances this process
some seconds.
may
be retarded.
short duration are either not apprehended at
incompletely, although no
Under some
Stimuli of
all,
or only
real difficulty of apprehension
the retardation in the development of

sensory impressions is considerable, the impressions fade
away before they are really perceived. Some very strong
is
present.
If
impressions may be apprehended, but they are more or

less incoherent because the connecting links and the
accompanying events reach consciousness only in an incoherent and confused form. This disturbance of apprehension in its pronounced form is encountered in senile
dementia (presbyophrenia) and Korrsakow's psychosis, but
exists in a much less marked degree in many other
psychoses, particularly of the delirious type.
The apprehension of external impression requires not
only the development of a percept of sufficient strength,
but also
absorption into the systematic interconnections

of our experience.
The vast majority of our impressions
Presenat any given moment are obscure and confused.
its
tations only become clear

of past experience in the
and distinct when they find residua

"
memory, resonators," as it were,
through whose sympathetic vibration the sensory stimuIt is through this process, which
lation is intensified.
Wundt
17
"
apperception," that each percept becomes

united with our past experience, through which alone it can
calls
be understood.
by memory
This supplementing the given impression

images greatly increases the delicacy of our
apprehension, but brings with
it
the danger of a falsification
of perception.
The most frequent type

hension
is
of the disturbance of
apprethe increase of the threshold value for external
The more
must be in order to
produce an impression, the more confused and defective
will be the picture of the external world.
The patients
stimuli.
intense the stimuli
apprehend only a small part of the impressions which

they receive. They fail to note and to understand their
We
environment.
call
gradual development
this
The
diminished sensibility.
of this disturbance of apprehension
found in simple fatigue and its transitions into sleep,

but also in the morbid states of extreme mental exhaustion.
Ether and chloroform isolate our consciousness from
is
the external world most completely and rapidly, but a

of narcotics act in a similar way ; such as, alco-
number
hol,
paraldehyde, and trional. Diminished sensibility
found
in fever,
and intoxication
is
also
deleria, as well as in the
clouded consciousness of epilepsy and hysteria.

Oftentimes
also found in the various phases of manic-depressive
it is
insanity, especially in the depressive and manic stupor,

but also in the more intense maniacal excitement.
The
tal
entire sensory experience in the first stages of mendevelopment remains on the plain of simple perception.
As long as the impressions
of the external world have left

no memory residue there is no network of psychological
associations through which new experience may be related
to the past.
In the severest forms of arrested mental
development
this condition persists,
and there
is
no possi-
18
bility of the
gradual clearing of the clouded consciousness.

It remains forever a confused medley of vague isolated
presentations and feelings, in which there

hension or order.
no clear appre-
At any one moment there

view only a limited number
Disturbances of Attention.
is
is
present in our inner field of

This limitation of consciousness
phenomena.
of mental
is
called the
"span
of consciousness.
chain of our psychical

of this span, our inner
life
"
Since the entire
must pass under the
limitations
life presents a constant coming and

mental processes. One experience after another
appears and disappears ; each approaches from the dark-
going of
ness of the unconscious, at first being indistinct and weak,

after a short time reaching the climax of its clearness and
strength,
another.
and then sinking from
within the
sight to give place to
This development of a mental phenomenon

field of consciousness is coincident with that
inner activity of the will which we call attention.

Our
sense organs turn to the forceful impressions, and those
presentations appear which strengthen the process that
claims our attention.
The
strain of attention
various degrees and directions.

tain physical phenomena ; such as,
It is
alterations in breathing, pulse,
may have
accompanied by
movements
and blood
cer-
of the body,
pressure.
Attention not only strengthens a developing impression,

but without doubt it retards its fading. In this way each
impression exerts an influence on
its
successors.
lation to their predecessor inhibits or promotes
opment.
Their retheir devel-
In this manner the primitive passive and aimless

and selective. It is not the force
attention becomes active
of the external impressions,
but rather the attention, which
determines our inner experience. Experience is determined

not so much by the strength of external impressions as by
19
In a child
the favoring or inhibiting effect of attention.
the content of consciousness is helplessly dependent upon
accidental circumstances it perceives only the most strik;
In adults, on the other hand, the process of

more and more dominated by personal tenden-
ing stimuli.
perception
cies
is
which gradually develop out of the experiences of the
individual.
We train ourselves to notice certain impressions
in preference to others, so that some stimuli, however faint,

have decided advantage over others. On the other hand,
we accustom
ourselves to be inattentive to regularly recurring stimuli, yielding them no influence over our psychic
This development of definite "points of view,"
processes.
interest, leads to an extraordinary
of consciousness, so that at the
the
threshold
variability of
definite
directions of
same moment when strong
stimuli pass quite unnoticed,
we
apprehend with greatest acuteness the slightest alterations

in
some special object.

The attention is variously
affected in different psychoses.

In the first place, in all conditions of advancing dementia
there is a blunting of attention.
Perceptions arouse no cor-
They are not united with the

and
they fail to incite him to
patient's past experience
pursue them further on his own initiative. In the case of a
deteriorated paretic the most striking occurrences may take
responding
memory
images.
place without creating any impression, although he may be

In dementia prsecox a
able to comprehend questions.
striking disorder of the attention is present from almost the
Particularly in the stuporous
inception of the disease.
states, all attempts to arouse the attention are unsuccessful,
even prodding with a needle, or touching the cornea, fails
to create
any voluntary movement.
of the attention
but a suppression
patients perceive well enough
This
is
not a blunting
of the attention.
The
what takes place about them,
20
but they involuntarily prevent the perception influencing

their thought or action.
Even all the external expressions
that accompany attention, such as the turning of the head
and eyes, and apparently also the alteration of the pulse

and breathing, are absent.
This disorder corresponds
with the negativistic processes found in disturbances of
volition and may be called a blocking (Sperrung) of the
attention.
In some stuporous states of manic-depressive insanity a
Here
retardation of the attention occurs.
also
it is difficult
to get into touch with the patient, but only because he lacks
that internal process which connects his external impressions
and
and incites the

The development of
his past experience,
of the attention.
difficult,
selective activity
ideas
is
rendered
not on account of deterioration in the mental
life,
but through the process of retardation which prevents the

perceptions from gaining any extensive influence over the
internal
life.
In manic-depressive insanity the external
expressions accompanying attention are usually preserved,

the patients look around inquiringly, although not understandingly. They look at objects placed before them and
turn the head at a noise.
An
immediate result of these disturbances of attention,
both blunting and retardation,
upon new
influence
is
perceptions.
the loss of their determining
single impression
may
be able to arouse the attention and be strengthened by it,

but the persistent continuance of this psychical process,
with
its
resulting choice of
the incoming perceptions,
is
An impression once aroused may last some time,

can always be displaced by a new stimulus, provided
lacking.
but
it
This is passivity of the

strong enough.
observed particularly in paresis and senile
It also occurs in the stuporous forms of manic-
only the latter

attention
which
dementia.
is
is

and
depressive insanity
in
many
of the
21
demented states
following infectious diseases.

patients resemble children who have never had experience, therefore have no ideas or memory pictures that
The
can be awakened to direct the attention. In those forms of

mental weakness, in which mentality does not develop be-
yond the grade of childhood, the attention throughout life

remains passive and lacks independence.
Distractibility of attention is the domination of the atten-
by accidental, external, and internal influences. Limitation of the attention arises through the want of ideas that
tion
have strength enough to influence the process of apprehension

is a greater flightiness of the mental
The attention leaps from one impression to
processes.
in
another,
spite of the fact that an endeavor is made to
;
in distractibility there
This disturbance regularly accompa-
direct the attention.
nies those mental states that exhibit increased irritability.

It is probable that in increased distractibility of the atten-
tion the separate impressions fade so rapidly that they

have no dominating influence upon the incoming percep-
Details are apprehended without a comprehensive

view of their relations, and the entire apprehension is
tions.
superficial.
The
lightest
form
of distractibility
mindedness of fatigue.
is
more
persistent, as
is
is
found in the absent-
In chronic nervous exhaustion

also the case in convalescence
it
from
severe physical or mental disease. It appears to a marked

degree hi the excited stages of paresis, sometimes also in
catatonia, collapse delirium, and in the infection psychoses,
but particularly in the manic forms of manic-depressive
insanity.
In these conditions a single word or the most
casual stimuli suffice to distract the attention.

Distractibility of attention
is
continuously present in some
22
forms of constitutional psychopathic states, where it exerts a very powerful influence upon the mental development.
The more distractible a man is, the less perception is controlled
by inner motives
coherent and uniform
is
arising
from experience, and the
less
the conception of the external world.
not to be confounded with hyperprosexia,

which consists in the total absorption of the attention by a
Distractibility
is
examples of which are found in the so-called

absent-mindedness of scholars and the complete absorption
single process,
of the melancholiac in his sad ideas.
DISTURBANCES OF MENTAL ELABORATION
B.
The material of experience, received through the different

and clarified by attention, forms a basis for all further
mental elaboration, and it is self-evident that both disturbances of apprehension, and the inability to make a systematic choice in the impressions, must affect to a marked
senses
degree the character of all intellectual processes.

All higher mental activity deDisturbances of Memory.
pends largely upon memory. Every impression which has

once entered consciousness leaves behind it a gradually fad"
ing disposition" to its recall, which may be accomplished
either through
an exertion
an accidental association
of ideas or
through
This disposition to recollection is

really identical with the residua which each new perception
contributes to the store of experience and to the resources of
memory.
of the will.
The residua are strong and permanent
in direct
proportion to the clearness of the original impression, and to

the multiplicity of its relations to other processes, i.e. to the
interest it arouses and to the frequency of its repetition.
The vast majority
of our ideas
and the greater part
of the
association complexes with which we have to do daily, are

so accessible to us that they appear of themselves under the
least provocation
and without any
effort.
dependent on impressiwhich
of
each
retentiveness,
bility
may be disturbed
independently of the other.
Memory
is
really a dual process
and on
Impressibility
is
the faculty for receiving a more or less
permanent impression made by new experience.

23
The
clear
24
apprehension of events, especially when aided by active

attention, increases this impressibility, while it is lessened
by difficulty of apprehension, by distractibility and indifference.
It,
therefore,
diminished wherever there
is
is
cloudi-
ness of consciousness, as in amentia, to a less extent in the

absent-mindedness of fatigue, and in the states of deterioration in dementia prsecox, paresis, and in epileptic insanity,
which are characterized by stupid indifference to the environment. The most marked disturbance of impressibility
occurs in Korssakow's psychosis and senile dementia, especially presbyophrenia,
although the
apprehended and
moment
impressions are
In these patients the

process of perception develops very slowly, so that with
those stimuli which act quickly the process of apprehension
well
becomes
assimilated.
distinctly impaired
and at the same time the pro-
cesses of consciousness fade very quickly.
In normal life it is the greatly diminished impressibility

which renders it difficult to recall our dreams. This demonstrates that psychic
exist
without
consciousness,
activity,
life,
and therefore consciousness, can
memory. Similar conditions of clouded

undoubted evidences of a psychic
with
but yet without memory, occur in epilepsy,
many
profound intoxications, and hypnotism.

"Retrograde amnesia," in which memory is more or less
delirious conditions,
permanently destroyed without clouding of consciousness,

occurs in epileptic, hysterical, and paralytic attacks, head
and some attempts at suicide, in which patients cannot remember the events which immediately precede the
injury,
attack.
Memory
Retentiveness of
for this period
memory
may
return.
for past events
depends upon the
previous impressibility, upon repetition and the native

tenacity of the individual memory. Its disturbance is
manifested by an inability to accurately recall former knowl-

edge and important personal events.
Lack
25
of impressibility
usually accompanies lack of retentiveness, but the converse

is not necessarily true, as impressibility is affected by cloudIn senility
ing of consciousness, while retentiveness is not.
the former
is
far
more disturbed than the
latter;
recent
events leave no residua, while remote events recur in memory with ease and accuracy. This is even more striking in
senile
dementia and
may
occur in paresis. In Korssakow's

may extend back to cover
psychosis the weakness of memory

a definite period of the life.
The accuracy
of
memory may be
normal conditions, accuracy
Even
disturbed.
in
In morbid
and in the developalways more or less falsified.
is
only relative.
change of personality or the emotions,
ment
of delusions, the past is

Vivid imagination and pronounced egoism imperceptibly
modify the memory of past experience even in normal life
self
with interesting
details, while the

becomes a more and more important factor. This is
stories are embellished
always exaggerated in disease, while in melancholia, persecutory and expansive delusions often color the
of the past until it seems like pure invention.
mixture of invention and real experience

"
paramnesia. There also exist hallucinations of
which consist
memory
is
called
memory"
found especially in paresis, paranoid dementia, and sometimes also

in maniacal forms of manic-depressive insanity.
It also
(Sully),
of pure fabrications, being
occasionally occurs hi epileptic and hysterical befogged

states.
But fabrications are particularly characteristic of
Korssakow's psychosis, and presbyophrenia, in which states

the gaps produced by disordered perception are filled in with
memory, including even incidents of youth.

These are often fantastic accounts of wonderful adventures ;
falsifications of
they
may
be modified by suggestion and are frequently
self-
26
contradictory (see p. 186). The delusion of a double existence may be produced by confusing present experience
with indistinct memory images of the past, so that every
event seems like a duplicate of a former experience. This

sometimes occurs transiently in normal life; in disease
may
it
for
last
months, and
is
found particularly
in
epilepsy.
Disturbances of Orientation.
of the
comprehension
and personal
Orientation
environment in
relations.
Our present
is
the
clear
its
is
temporal, spacial,
related to our past
experience in a temporal series through the function of

memory.
Only recent events are remembered with the
greatest distinctness ; while the rest is grouped around
more or less isolated points, which form the basis for the
general chronological arrangement of our experience.
In
Spacial orientation is partly dependent on memory.
the
first place,
memory
enables us to recognize immediately
parts of our present environment, while
environment
even an unknown
may be comprehended
through our experience

motives or conditions for the
when the
latter includes the
former.
But apprehension may also play an essential role

In any unknown environment into
in place orientation.
which one happens to be placed, the process
of perception
real
the
situation
up
by bringing about a
connection between the immediate impressions and our
This often involves more than a mere
past experience.
regularly clears
identification of the present with the past.
from a more or
less
It
may
result
complicated process of reflection
and
In the same manner, orientation as to persons

from the cooperation of memory, perception, and
judgment.
Thus it becomes apparent that lack of orientation or
disorientation may arise from disorder of memory, from dis-
reasoning.
arises
27
order of apprehension, and from disorder of judgment. In

many cases two or more of these causes are combined.
Further, the disorder may involve all the fields of orientation or it may be limited to a single field, so we may dif-
between total and partial disorientation. The

apprehension of the environment may be prevented by
ferentiate
the fact that the patients cannot elaborate their external

impressions, or by an inhibition of thought, or by a
clouding of consciousness with or without falsification of

The first case is very common in dementia
perception.
pracox, where the disorientation usually results from the

lack of mental activity, and may be called an apathetic
is no difficulty in perception.
The
to
understand
lack
the
the
inclination
patients simply
meaning of what they see and hear, so that for weeks at a
disorientation.
There
may give themselves no concern as to where

how long they have been there, or whom they see.
time they
they are,
In the depressive phases of manic-depressive insanity
the apprehension of the environment is rendered difficult
through the presence of retardation and there develops

The patients perceive details
a condition of perpkxity.
The diswell enough, but they fail to synthesize them.

orientation in the most pronounced manic states may
perhaps be similarly accounted for, as there accompanies
it a marked difficulty in the apprehension and elaboration
of external impressions.
The
different forms of clouding
of consciousness in focal lesions of the brain, in epilepsy,
and
in alcoholics cause a
of orientation.
more or
pronounced disorder
In the delirious states found in infection
and intoxication psychoses,
less
also in hysteria
and
epilepsy,
there exist, besides the lack of clearness of apprehension,

also sense deceptions, both of which cloud and falsify the
picture of the environment.
28
Korssakow's psychosis there is an amnesic disorientation which depends neither upon disturbances of appreIii
hension nor of perception.
While in
this condition place
usually well retained, the patients are absolutely helpless as regards time.
They do not know when
they came into the institution, when they were last visited
orientation
by
is
relatives,
when they
last dined, etc.
Events
of a
month
ago may be referred to as occurring yesterday, and again

an occurrence of yesterday may be mentioned as happening months ago.
This amnesic form of disorientation may occur even more
strikingly in presbyophrenia, where on account of the marked
disturbance of perception in connection with the difficulty
of apprehension, mental elaboration of external impressions
is
almost impossible, hence patients
fail
to get
any idea
of
their environment, although details are understood without

difficulty.
The amnesic form
in paresis,
where time orientation
of disorientation also occurs

is
most often at
fault.
Amnesic disorientation occurs in other psychoses, indeed,

wherever the disorder arises from faults of memory. One's
own experience in orienting himself upon awakening from
a sleep or after fainting indicates how difficult it is to regain
time orientation after a severe clouding of consciousness.
The delusional form of disorientation is quite different.

Here we have to do with a faulty mental elaboration of impressions which are correctly perceived and apprehended,
leading to a false opinion as to the environment in its temporal and spacial relations. The patients are not clouded,
but they maintain delusional ideas as to the time, place,

and persons. Illusions or hallucinations may be the basis
mistaken personalities and the assertions of paranoid patients that they are in prison, in a bad
for such beliefs, as in
house, etc.
29
Disturbances of the Formation of Ideas and Concepts. Most of the complex ideas of normal life are composed of
heterogeneous elements, furnished by the various senses. In

these complexes the importance of the material furnished by
any one sense depends upon the peculiarities of the individual.

For some, vision is the most important sense, for others
audition; but both of these senses
may
be entirely lacking
without preventing a high development of ideation.
On the
other hand, lack of permanence of sensory impressions and

imperfect assimilation always interfere with the formation
of
complex
This
ideas.
is
illustrated
in congenital
and
acquired imbecility.
The formation
of concepts is the necessary condition for the
development of ideation. In normal life those elements of experience which are often repeated impress themfullest
selves
more and more
strongly, while the accidental varia-
more and
The concepts thus developed
tions of each individual experience are driven
more
into the background.
are a sort of
composite photograph or generalization of
experience.
These concepts are the most permanent and most easily

reproduced of all our ideational processes. But even these
not be reproduced in totality. More and more in the
developed consciousness single elements of these concepts
may
are
made
The exact form
to stand for the whole.
of this
often accidental, as when some

The
single image comes to stand for the total concept.
in
form
of
this
is
found
the
abbreviahighest
development
tion of thought by the use of linguistic symbols, i.e. when a
abbreviation of thought
is
word stands for the idea.

In morbid conditions, especially
this
may
development
may
stop at
in congenital imbecility,
any
cling to individual experience
point.
The patients
without being able to
30
sift
out the general characteristics of different impressions

They are unable to find concise ex-
of a similar nature.
pressions for more extended experience; the essential is

not distinguished from the unessential, the general from the
particular.
it
This not only prevents the development of thought, but

also retards the assimilation of new material.
New im-
pressions find no point of attachment in the mental life;

they cannot be arranged or systematized, and pass rapidly
In acquired imbecility the residua of earlier
into oblivion.
experience
may
partly conceal the inability to receive
new
impressions and to form new ideas. Later, however, this

defect gradually becomes more evident.
Similarly in
paresis, dementia praecox, and senile dementia, the circle
and general ideas and concepts are gradually replaced by the specific, the immediate, and the tangible.
New impressions are no longer elaborated and the most
of ideas narrows,
recent experience is quickly forgotten, while the memory

of the past is still fairly constant.
In direct contrast to this is the disturbance produced by
morbid
similar
excitability of the imagination,
and even contradictory
which correlates
ideas.
dis-
Such forced and
arbitrary combinations naturally interfere with the normal

development of concepts. Thus the foundation of all higher
mental activity becomes a mass of confused and indistinct

psychic structures, which can give rise ojnly to one-sided
and mistaken judgments as soon
as the patients
leave
the region of immediate sensory experience. The tendency

to reveries and dreams, lack of appreciation of facts, impossible plans and chimeras, so often found in imbecility,
paresis,
and paranoid dementia, are
clinical
forms of
this
disturbance.
Disturbances of the Train of Thought.
The
association of

ideas
may be
divided into two groups
external
31
and internal
associations, the former being effected by purely external

or accidental relations, while the latter arise from a real
coherence in the content of the ideas.

External associations usually arise through the customary
connection of ideas in time or space, of which thunder and
an example; or through habits of speech, in

which a definite association of words becomes so fixed by
frequent repetition that one word always calls up the others,
Sound associaas in quotations and stereotyped phrases.
form
and
extreme
of
this
an
tions,
important
type, are based
either upon similarity of sound or of the movements of the
vocal organs, as seen, for example, in a morbid tendency
to rhyme.
This disturbance may be so marked that the
lightning
is
associated sounds are altogether meaningless.

Internal associations depend upon the logical arrangement of our ideas according to their meaning. The association
between
different individuals of the
or different species of the same class,

instance, the association of boy with
The special form

animal,
which emphasize some particular
etc.
of
is
same
species,
of this kind;
man and man
internal
for
with
associations,
characteristics of a con-
cept, usually attributes, states of being, or activities,
means
is
of
called
which a preceding idea

predicative
association.
is
by
more closely defined,
That the dog is an
animal belongs to the first class of internal associations;

that he is dark-colored, or that he runs, belongs to the
second.
Paralysis of thought, the simplest form of disturbance of
the train of thought, is characterized by complete absence
of all associations.
It begins as a more or less marked retardation,
and develops
into characteristic
distractibility of thought.
It occurs in
monotony and
a moderate degree
32
Narcotic poisoning presents severer forms.
in fatigue.
It
a fundamental symptom in the psychoses accompanied

by deterioration paresis, dementia praecox, and senile deis
mentia.
Retardation of thought is manifested by difficulty in the
elaboration of external impressions ; the train of thought is
markedly retarded, and the control of the store of ideas is incomplete. It may bring the train of thought to a complete
In contrast to the paralysis of thought, to which
standstill.
presents a
it
superficial
similarity,
this
inhibition
may
suddenly disappear under certain conditions, as fear. The

they are not, like the
patients do not lack mental ability
;
weak-minded or deteriorated, obtuse and indifferent, but

they are unable to overcome this restraint which they themThe most pronounced form of
selves very often realize.
this disturbance is seen in the depressed and mixed forms
of manic-depressive insanity, and perhaps, also, in the disturbance of thought in epileptic stupor.
The
disturbances of the content of thought are best understood as a faulty arrangement of the individual links of our
thought with relation to the goal ideas.

usually directed
is
by
definite goal ideas,
Normal thought
and of the ideas
which appear in consciousness, those elements are specially

favored which stand in closest relation to these controlling
goal ideas. Out of the large number of possible associations
those only really occur which lie in the direction determined
by the general goal of the thought process.
In morbid conditions the train of thought

rupted by
an
be inter-
prominent emotional tone (cf. Melancholia,

of some sad experience or a fright
so dominate us that our thoughts in spite of all effort
especially
p. 355).
may
may
individual ideas, or other trains of thought with
The memory
return to the same channel.
33
Compulsive ideas are those ideas which irresistibly force

themselves into consciousness. These are usually accompanied by a disagreeable feeling of subjection to some
overwhelming external compulsion. The mere fear of their
them into consciousbasis

of emotional dison
a
They usually develop
turbance, and, therefore, accompany melancholia and derecurrence
is
often sufficient to bring
ness.
pressed phases of manic-depressive insanity, also sometimes

the depressive states of dementia praecox. The content of
these impulsive ideas is unpleasant and harassing.
The
patients are compelled to think constantly of some shocking
experience, which they have had, or to depict some mis-
which may befall them. The profound emotional

despondency which serves as a basis for these thoughts and
at the same time furnishes a good soil for their development has associated with it a feeling of compulsion. As the
disease develops, despondency becomes more predominant,
fortune,
the resistance of the patient to the ideas is

gradually weakened, so that the feeling of subjection vanIn this way the original compulsive ideas are transishes.
particularly
if
formed into delusions.

If the fundamental emotional state is independent of
morbid changes of the emotions, as encountered in various
psychoses, the disturbing factor in the compulsive ideas does

not reside so much in their content as in the fact of their
The most striking forms of these comideas

in
the states of hereditary degeneracy
pulsive
develop
Increased emotional sus(cf. Compulsive Insanity, p. 498).
constant recurrence.
ceptibility, as well as
a tendency to morbid introspection, are
the fundamental states from which these compulsive ideas

In the very lightest forms there develop ideas
develop.
which are unpleasant.

There is still another group of cases
in
which some
34
common
simple
ideas
with
interfere
the
development
such as
the name of some one, which may
of every train of thought, later gaining mastery;
the compulsion to recall

become so prominent that the patient makes out a long list
of names, and finally indexes the names of every person
whom
sort
he meets.
The compulsion
and again there
is
to count
is
of the
same
the compulsion to ask of them-
selves all sorts of questions (Gruebelsucht) (cf. p. 500).

There is here a feeling of uncertainty which incites the
patient to a distinct
effort,
which
feeling
can never be
quite satisfied, because every suggestion leads to still another series. There is no end to the names, the numbers,
and the questions to be asked. The

is,
real basis for these ideas
therefore, a feeling of discomfort, identical with that
which
incites all of
us to seek for clearness and truth ;
but in the case of the patient these ideas are no longer

the servants, but are masters of the psychical personality,
because he has not the power to suppress them when they
hinder the train of thought.
Distinguished from the compulsive ideas are the simple
unaccompanied by marked unpleasant feelcompulsion. This phenomenon is probably due to
persistent ideas,
ings of
the absence
of
definite
or
fixed
the train of
goals in
a view which is borne out by our experience

thought
with the persistence of some of our own ideas, whenever we
give free rein to our thoughts. Rhyme, verses, and melo-
sometimes cling to us even in spite of our

throw them off.
dies
In gross brain lesions there
is
often found a
Words
persistency of linguistic expressions.
used shortly before are repeated by mistake.
naming objects use words which they have
spoken.
Fatigue
may
efforts to
peculiar
and phrases
Patients in
just heard or
so aggravate this disorder that
it is
35
impossible to secure a correct answer, as one gets only a

monotonous repetition of previous statements.
In another phase of the disorder, more or less motor to

be sure, patients use an indicated object in the same way
previously and correctly used another.
In
Neisser happily names this disturbance perseveration.
they have just
some
cases
of senile
dementia with pronounced
persist-
ency of ideas, Schneider has pointed out that ideas once

aroused develop very slowly. In fact, in perseveration,
one often has the impression that the patients fail to understand the new perceptions and when forced simply repeat
Patients only
themselves.
named a
picture right after one
If this hypothesis
or two other pictures had been shown.
not
is
conditioned
so much by the
the
disorder
correct,
is
peculiar stubbornness of a particular idea, but rather by

the difficulty of releasing other ideas to displace it.
One should
distinguish carefully from perseveration the
tendency "to run to death the same ideas" so often occurIt is but
ring in dementia praecox in a pronounced form.
another expression of stereotypy of the will. Examples of
this condition may occasionally be encountered in children.
It
consists of
an impulsive, often
limitless repetition of
similar expressions, sometimes alone and sometimes interwoven in other more or less incoherent trains of thought.
The content
and is not,
of these stereotyped ideas
is
quite accidental
as in simple persistent ideas, determined by

that which has preceded.
In morbid conditions, even when the collection and
new
prevented by mental
disease, there remain some residual ideas of the normal
This results in a
state, fixed by constant repetition.
monotonous content of consciousness with a marked imelaboration of
impressions
poverishment of the store of ideas.
is
This occurs in senility,
36
paresis,
and other deterioration
train of ideas
may
shrink
a few words which are
processes, in which the

to a few phrases, or even
repeated over and over. These
down
phrases, in contrast to the persistent ideas of the catatonic,

are not senseless, but actually express the content of the
The following is an example:
patient's consciousness.
"
Frazier went away this morning, will be back soon.

Didn't ask
him what time he'd come home. Frazier is working up in the lot
I was up in the lot yesterday.
I forget what I
at something.
went
what
Frazier
for.
cared about
is
it.
He asked me
talking of selling the place.
Father is going over there to-day. Father
He didn't speak to me he is downhearted.

should bring up his boys to work upon it. Frazier don't have
time to work. He don't stay home much. I would advise them
don't care for the farm.
He
to
have a place and keep
it.
If I get well I will
keep
it, if
I can.
The boys would like to have some farm. They won't stay in a place.
Frazier don't like to work on the farm.
[Patient hears a woman
coming up the hall.] Some woman I hear coming. If she was on
a farm, she wouldn't handle much money. If they sell the place,
the children will starve for hunger.
[Patient looks at her hand.]
I
am
If
he
all
blacked up. I have been out on the farm a good deal.

the place, the little children will starve for hunger," etc.
sells
Circumstantiality is the interruption of the course of

ideas by the introduction of a great multitude of nonessential accessory ideas,
which both obscure and delay the
train of thought. The disturbance depends upon a defective estimation of the importance of the individual ideas
in relation to the goal ideas.
The goal may, indeed, be
ultimately obtained, showing some real coherence, but

only after many detours. The simplest form of circum-
appears in the prolixity of the uneducated,

who are unable to arrange their general ideas in accordance with their importance, and show a tendency to adhere
stantiality
to
details.
Some even have
difficulty
in distinguishing

sharply what
The
37
actually seen from what is simply imagined.

circumstantiality of the senile is probably due to the
is
disappearance of the general ideas and concepts. Circumstantiality is also present to a marked degree in epileptic
which the following passage taken from the

bibliography of an epileptic is an example
insanity, of
"
Before one believes what others have told him or what he has
read in the almanacs he must be convinced and examine himself
before one can say and believe that a thing is beautiful or that a thing
is
it,
not beautiful ;
first
and then, when
through
it
investigate, go through
it
yourself,
and examine
man
has investigated everything and has gone

himself and examined it, then man can at once say the
is not beautiful or not good ; therefore, I myself

say, if one will make a statement about a thing, or will sufficiently
establish something or will speak in conformity with the truth, the
thing is right or is not right, so must every man likewise examine
thing
is
beautiful or
the thing as he believes himself responsible before the tribune God,

and before his Majesty the King of Prussia, William the Second,
and the Emperor of Germany.

"
soldiers have done to me.
I will
now
relate further
what the
The absence
or incomplete development of goal ideas

gives rise clinically to two important forms of disturbance
of the train of thought: (1) flight of ideas, (2) desultoriness.
The
of ideas
is
first effect
of a defective control over the train
a frequent and abrupt change of direction.
The
train of thought will not proceed systematically to a definite aim, but constantly falls into new pathways which
are immediately abandoned again. The impetus for such

changes of direction can arise from both external stimuli
and from
internal processes.
In flight of ideas the instability of goal ideas produces
a condition in which the successive links of the chain of
thought stand in fairly definite connection with each other,

but the whole course of thought presents a most varied
38
change of direction. The patient is unable to give long

answers to questions, and cannot be held to a problem
requiring much mental work, because ideas once aroused
are immediately forced into the background by others.
This is a fundamental symptom of the manic form of
manic-depressive insanity, and also occurs in acute exhaustion psychoses, infection deliria, paresis, occasionally also in
It may
fatigue of normal life and especially in dreams.
appear in alcoholic intoxication. There is no great wealth

of ideas, but on the contrary it is often accompanied by
a conspicuous poverty of thought. Moreover, the rapidity
of the association of ideas is not at all increased, but
on the other hand
is
usually diminished.
The
patient's
incoherence, therefore, depends simply on the lack of that
unitary control of the association of ideas which represses
all secondary ideas and permits progress only in a definite
As the
any accidental idea which

would normally inhibit the goal idea may assume importance. It is not, then, the rapid succession of ideas which
direction.
result of this,
warrants the designation of a
insta-
bility of single ideas
influ-
flight of ideas, but the

which are unable to exert any
ence over the course of the train of thought.

In flight of ideas the direction of the train of thought
is determined by external impressions, chance ideas, or
finally
by simple
associations, external or internal.
influence of chance ideas
is
The
well demonstrated in intoxica-
tion deliria, and especially in opium intoxication, in which

vivid ideas of the imagination follow each other in a varie-
gated series, giving rise to an incoherent progression of

unrelated fancies, to which experience offers no key. This
might be called the
The rambling
delirious
form
thought of the
another form of the flight
of flight of ideas.
hypomaniacal patient is
of ideas in which the patients

diverted
are
incidents,
ject.
The
when she
"
and
reminiscences, and
need to be frequently led back to their sub-
by unimportant
following
left
39
is
ideas,
an example (the patient being asked
the Hartford Retreat)
My mother came for me in
She had on a black bomown and got another from neighbor Jenkins. She lives in a little white house
Come up with an old green umbrella 'cause
kitty corner of our'n.
You know it can rain in January when there is a thaw.
it rained.
Snow wasn't more than half an inch deep, hog killing time, they
bazine of Aunt Jane's.
One
January.
shoestring of her
butchered eight that winter, made their own sausages, cured hams,
and tried out their lard. They had a smoke house. [But how
about your leaving Hartford?] She got up to Hartford on the
Dr.
half-past eleven train and it was raining like all get out.
Butler was having dinner, codfish, twasn't Friday, he ain't no
back to the door and talked and laughed
Catholic, just sat with his
and talked."
Here, in spite of many diversions, we see a fairly good

sequence in the content of thought which centers around a
the patient's mother.

In the following example, on the other hand, the predominance of motor speech ideas has led to a massing
visit of
of habitual speech associations, combinations of
common
words, and finally to simple sound associations. It might

be called an external flight of ideas in contrast to an internal
flight of ideas characterized
"
was looking
by
internal associations.
at you, the sweet boy, that does not want sweet

Neatfor the hardware store.
You always work Harvard
soap.
ness of feet don't win feet, but feet win the neatness of men.
Run don't run west, but west runs east. I like west strawberries
"
best.
Rebels don't shoot devils at night.
The
train of thought is supplanted by fixed and familiar

phrases, in which the influence of linguistic ideas clearly
40
outweighs that of the content of thought; while sound
and quotations, etc., stifle all internal

The most favorable condition for the appearform is an increased motor excitability and
associations, rhymes,
associations.
ance of ^this
alcoholic intoxication.
Desultoriness, the second
is
speech,
more
difficult
form of
type of incoherent
to characterize, as it is not well
this
the external form of speech is fairly

well retained, but there seems to be a complete loss of goal
ideas, while an incoordinate mass of ideas follow each
In
understood.
it
other aimlessly and abruptly. In the flight of ideas we

were able to discover some connection, if only the most external,
between the separate links of
led to a
new
ideas,
which gradually
chain, until the original standpoint
was en-
In desultoriness there is no recogsight of.

nizable association between the successive ideas, while the
tirely lost
move along for some time in simiare

confused and contradictory. In
phrases. They
flight of ideas the course always tends toward changing
trains of thought often
lar
and hence never attained
goals,
and is, therefore, always

on the other hand, the
entering new circles;

train of thought does not progress at all in
in this form,
tion,
any one direcbut only wanders with numerous and bewildering

the same general paths, the following of
an example
digressions in
which
is
MIDDLETOWN, Dec.
DEAR SISTER
15, 1901.
your box in perfect shape and money as well. Do

you wish to see me. If you care or somebody else will. Do. Awful
lonesome. A new suit and fair words. This time give me a little
money if you will (tell her to use slang my front yard). Give me
a punch for fun. You are read that way) leave (Give her a drop
I received
of
your poison).
Latest song attendant.
(Give her a wife she
is

Hill St.
lonesome).
me
suppose
give over
Tom
Pa Ma
41
Kellhams Pete whair Fitch.
Nell Har.
Will Eddy. I strong

don't you know he passed it to the other young from Newark but
he could not start it. He did not know where it came from. He
tell
Right
I got McKingleys Son over me at times he works on

sleeps under.
the stylish horse. He is a black strong. I am a red. You know
the Pres. Brokerage and drink cigars and walks, speeches.
He is
37 Port Rhoda he served 10 years at his trade he is working 14

good mack. Tell Burnie he is liked by him but not strong enough
they live 9,000 miles in the air over the three miles you read in
school. ...
Pa Pa you know the stove he carried. 1,700 Ib.
trunk strong nature, hard life when I got to let him know how on
pipe here through the converser the head electro gave
and they don't speak and it was a corn sense.
for sense
now good
Yours
by.
me
I
a dime
am
bed
Aff.
and external
Distractibility through internal
influences
be present to a marked degree, but the newly

may
aroused ideas do not serve as bases for others, but simply
intrude into the desultory train of thought in an incoherent
also
In this
manner.
their
incoherent
way
it is
jumble,
often possible, in the midst of

obtain coherent replies to
to
The
following is an example of this (the physician's questions are enclosed in brackets)

questions.
"
[Why are you here ?] Because I am the empress. The dear

parents were already there and everything was already there and
had given me permission. I have also learned stenography. Why,
David, how are you? Even a member of the reserve, megalomania, empress. [Do you feel well ?] Oh, thanks, very well, since
the government has given me permission we will be good friends.
Oh, God
my
brother Carl David the
write something.
[What
is
that?]
[Why
are
first
you here?]
Nothing, nothing, at
all.
and Olga. Ah, let me

Insane.
Megalomania.
[How
old are you?]
you come again ?] I do not know. When he

comes I will not run after him (laughs). I must always be close
I have nothing (grasps at the watch chain.
(clasps her hands).
But the chain is nothing. How I will at once see what time it is. "
22-7-1872.
[Will
42
This example does not show, however, the repetition of

single words or phrases which so frequently occur in the
catatonic productions,
and
is
shown
in the following
"You don't own this building, I know that. The Hartford

pigpen never supported, never confirmed food, therefore are not
supported and this building will pay for that and food which conWhite immortal eternal receipt for that food. The war
I have the white immortal eternal receipt.
Mars
planet Mars.
war planet, or war world Mars. The war world or the war planet
Mars. White immortal eternal receipt for its existence and confirmation receipt. The Hartford pigpen is not supported or has
firmed
it.
not confirmed food or the laws of food, therefore will not be supported by those who have confirmed food. The white immortal
eternal receipt."
In extreme desultoriness the speech consists of a mere

series of letters, syllables, or sounds, while in the severest
always some goal idea even

though it rapidly changes, and the majority of the expressions consist of actual words; here there is a perfectly
senseless repetition of the same sounds with only insignififorms of
flight of ideas there is
cant modifications, like the following:

"
Ellio, ellio, ellio altomellio-altomellio,
f. f. f.
f. f.
dear father,
f. f. f.
dear father,
selo, eloo,
e. e. f .
old and
devo, heloo
new
f . f . f.
Catholic Church,"
and so on in monotonous repetition. Sound associations

seem to play an important role here, but the train of
thought does not advance through it to new ideas.
These disturbances which destroy or interrupt the internal coherence of thought gives rise to what is called confusion of thought, which is a prominent symptom of mental
disease.
This
symptom develops
variously.
If
the inter-
ference with the coherence of thought arises from flightiness

of the goal ideas, then we have a form of confusion charac-

terized
by
flight of ideas
verbal associations.
with
its
43
tendency to external and
The abrupt development of many differ-
ent ideas without order, and not leading to any definite goal
There may also
idea, gives rise to the desultory confusion.
be differentiated
still
confusion, which
is
another form of confusion, dreamy

In
characteristic of delirious states.
type there exists besides the disturbance of apprehension and the rapid fading away of the perceptions, a
marked prominence of sensory elements in thought. There
this
is
also a combined
form
of confusion, in
which there
is
new trains of thought

each
other
The
head fairly swims
following
incoherently.
because there is not an opportunity to marshal or survey
transitory appearance of abundant,
the rapidly appearing ideas. This type of confusion characterizes those forms of mental disease in which the rapidly
appearing thoughts are elaborated into a permanent
delusion formation, in the
same way that
in
normal
life
a person gradually works into his train of thought a new

idea that at first was confused. Also the presence of many
be regarded as a cause of an hallucinatory confusion, just as a normal person sometimes loses his
orientation if he is suddenly placed in an inextricable
hallucinations
may
environment with new and puzzling impressions.

Mental retardation can also produce a form of confusion
of thought, through the slowing of the process of comprehension and mental elaboration. This has been designated stuporvus confusion. In it one sometimes encounters
a combination with a genuine flight of ideas. Finally the

emotional attitude may play a very important role in the
development of different forms of confusion of thought.
In some diseased mental states with marked disturbances

of the emotions, this element is of great importance.
Disturbances of Imagination.
The fund
of our earlier
44
experience becomes of most value to us when we are able to

bring from it into consciousness voluntary ideas and mem-
This ability is provisionally named imaginaIt requires on the one hand reproducible residua of
ory images.
tion.
former mental processes, and on the other hand that process

which enables us to formulate new mental pictures out of
the simple residua of memory and make it possible to elevate ourselves above our simple sensory experience and
perform original mental work.
The power
of imagination may be seriously disturbed in

In some degree this is observed in simple mental
fatigue, also in poisoning with narcotic and hypnotic drugs,
but more especially in the severe grades of deterioration
disease.
paresis, senile dementia, and other mental disIn these latter disturbances the atrophy of the
found in
eases.
usually combined with defective memory.

ideas are not only not at one's disposal, but they may
imagination
The
also in large
is
numbers disappear.
Where
this loss is less
extensive, as, for instance, often in epileptic insanity; there
develops a simple sluggishness (Schwerfalligkeit).
These patients still have some command of their store of ideas, but
they require a very long time and considerable stimulation.
The retardation which is encountered in the depressive

and mixed phases of manic-depressive insanity is to all
external appearances similar to sluggishness. The disturbance of thought processes of the befogged states of epileptic
and hysterical insanities probably also belong here. Retardation differs from sluggishness in that it is a transitory
Retardation is
state, while the latter is a permanent one.
usually accompanied
ground which exert
by alterations in the emotional backsome influence over the function of
imagination even in normal
life.
elaboration of external impressions
In
is
it
one finds that the
rendered
difficult;

indeed,
it
may
even be so
much impaired
as to cause
45
com-
plete perplexity, owing to the lack of memory pictures;

the patients cannot think of anything, they lose all connec-
tion with their earlier experience, and sometimes cannot

even give the names of their nearest relatives. Nothing
Thought seems to come to a standstill.

Such patients may present the external appearance of profound dementia but the fact that all of these severe disturbances suddenly disappear indicates retardation, moreoccurs to them.
over the patients suffering with retardation themselves

recognize the resistance against which they have to struggle.
indifferent as demented patients
are
are; they
simply unable, in spite of great effort, to
overcome the constraint of thought.
They are not stupid or
In the indifference so characteristic of dementia praecox

there is no resistance offered to the activity of thought,
but there
is
mental work.
a more or
less
complete lack of motive for
If these patients are sufficiently stimulated,
they are able to call up some of their favorite ideas, but

they are never forced to mental work of their own accord.
of what happens to them, and they
have no thought of the future. Mental activity stagnates
more and more, and there gradually develops a shrinking
a sort of atrophy from disuse. In
of the store of ideas
contrast to the paretic they often surprise one by the occasional display of a much greater wealth of ideas than
This very rarely
it was supposed they actually possessed.
in
of
the
deteriorated
dementia
happens
stages
paralytica.
This observation confirms the belief that in dementia
praecox there is a real loss of mental activity.
Morbid excitation of the imagination is evidenced by a
special vividness of the memory images, which under cer-
They take no account
tain
circumstances acquire the strength of sensory im-
46
pressions.
states,
This occurs particularly in the different delirious

is almost always present a pronounced
where there
disturbance of apprehension. Another example is found in

of the anxious states of melancholia, manic-depressive
insanity, and of the psychopathic states, in which the
some
patients detail their fears with painstaking clearness
and
completeness.
In the excited stages of manic phases of manic-depressive insanity, of paresis and of catatonia, it is a question
whether there really is an increase of the imaginative

power. One might judge that there was no question as
to this in the manic phases of manic-depressive insanity,
but really the realm of ideas here is barely,
while it very often is even diminished.
patients assert that they
abound
in ideas,
circular depressive phases patients

assertion, in spite of retardation.
if
at
all,
Some
enlarged,
of these
and even
may make
in the
the same
There
is, however, good

reason to believe that there really exists more of an increased distractibility and flightiness of the internal
processes than an increased production of ideas.

persistent increase in the activity of the imagination
is found in a considerable group of psychopathic individuals,
such as the morbid adventurer and inventor, who in the

pursuit of their extravagant plans completely lose sight of
life, keeping their gaze fixed only upon the
the realities of
results,
while they never take into serious consideration the

and insufficiencies of their methods. Then there
difficulties
the dreamer, who gives himself up to reveries. Finally

there are the morbid liar and swindler, who take the greatest
satisfaction in the variegated pictures of their busy imaginais
tion.
Great activity of the imagination regularly accompanies

an increased susceptibility of thought to external and inter-

nal causes.
in children
tibility
to
47
In normal individuals this trait is exhibited

and women. Morbid suggestibility and suscepautosuggestion are regular accompaniments of
psychopathic states, especially the hysterical conditions. They are manifest here not only in the accessibility of
many
thought and feeling to striking impressions and persuasion,

but also in the appearance of all kinds of physical symptoms which are released through the medium of emotional
states.
Judgment and Reasoning.

Judgment
and inference are the most complex products of the intellect.
Since perception, memory, the formation of concepts, and
Disturbances
of
the association of ideas are their necessary preconditions,
they
will
be more or
these processes.
less affected
But
by every imperfection
of
this is not the only source of their
derangement.
Human
free
action
source
is
of
the
mind
itself
experience,
(imagination).
of
and the
Neither
the other;
independent
empirical
never free from preconception and expectawhile even the wildest imagination employs material
knowledge
tion,
knowledge has two sources

entirely
is
which originally came from experience.
Nevertheless,
sharply differentiate empirical knowledge
from pure
which
arises
we
belief,
from the recasting and interpretation of
experience.
Primitive people do not
draw this distinction. Their

and
traditions are as credible
mythological interpretations
to them as direct experience.
Even in children invention
and experience are sometimes only partially differentiated.
Whenever invention can be easily tested by direct experience the line between the two becomes more and more
sharply defined; but even here the natural incompleteness
of our apprehension or our habits of thought may lead us
48
into error.
If the
data furnished by experience is scanty

is free to fill the field with its
or unreliable, imagination
own
creations.
[Empirical science has slowly supplanted many of the

misconceptions of primitive thought, but superstition still
survives among the uncultured; while even among the
cultured there are beliefs which no experience or arguments
can shake. The essential characteristic of these beliefs
is
their emotional significance for the individual.
Dog-
matic opinions, ideas firmly fixed by tradition, education,

and habit, acquire an overwhelming emotional value, and
not only persist in spite of experience, but even mould
experience into conformity with themselves (cf. the force
of prejudice). The emotional significance of such beliefs
has its basis in their relation to vital interest.
feeling
of helpless dependence and insecurity in the presence of the
unknown and mysterious

in primitive races.
Even
is
the
fertile soil of superstition
in most highly cultured persons

and
religious convictions, although more or less
political
dependent on the rational elaboration of experience for
their content, are characteristically inaccessible to opposi-
tion
and argument/}
These peculiarities of normal thought help us to understand the delusions of diseased consciousness.
Delusions
are morbidly falsified beliefs which cannot be corrected either
by
argument
or
or
experience.
deliberation,
experience
often associated with actual
They do not
but from
and
belief.
arise
from
Although
falsified
perceptions (hallucinations or illusions), they are always due to a morbid

interpretation of the events arising in the patient's own
imagination. The tendency so often encountered in health,
draw sweeping conclusions from insufficient data or to

assume a causal relationship between purely accidental
to
49
occurrences, becomes an important factor in morbid conditions; the most innocent events are construed as mystic
symbols of secret occurrences, and simplest facts are full of

mystery. The flight of a bird is an omen of good fortune;
an accidental gesture reveals sudden danger.

Further proof of the subjective origin of delusions is
found in the close relation which they maintain to the
Just as in health the self forms the
ego of the patient.
our
for
of
reference
thoughts and feelings, so in disease
point
the mysterious creations of the imagination are most intimately connected with the patient's own welfare. The
delusions are, consequently, never indifferent to the patient
except in cases of advanced deterioration. They are not
only referred to the self, but they exercise a marked influence

over the patient's emotional attitude to ward his environment.
Delusions are inaccessible
not originate in experience.

able to correct
Only
them
in convalescence,
argument, because they do

Experience, therefore, is un-
to
as long as they remain delusions.
when they become a mere memory
of delusions, can they be recognized as false.

At the height
of the disease they are as firmly established as reason herself.
So long as the morbid conditions which give
rise to
them
the delusions are unchanged. If they are relinquished or modified, the change is not due to argument,
but to a change in the morbid condition. Our argument
persist,
drive the patient to admit non-essential points, but

the delusion serenely reasserts itself, notwithstanding the
may
most evident
Even when the extersupport is destroyed, a new one
self-contradiction.
nal object of reference or
quickly found. The delusion needs no other support than

the absolute conviction of the deluded.
is
Vivid emotional
states,
such as
and enthusiasm are important
fear, sorrow, anger, joy,

factors in the origin of
50
delusions.
for
us,
in
Even
in health, anxiety and enthusiasm create

the consideration of any subject, fears and
hopes which really have nothing to do with the subject

matter. In morbid conditions, sorrow and fear exert the
strongest influence on the falsifications of ideas.
Clouding of consciousness is sometimes a factor in the
development of delusions, especially in delirious states.

Delirium tremens and fever delirium, for instance, present a host of fantastic delusions with but very little emotional disturbance.
believed one day
Moreover, delusions which are firmly

may be recognized as false the next,
clearly indicating a morbid condition of consciousness,

which rendered their correction impossible. We have an
example of this in dreams, where we are unable to detect
or correct those contradictions which are perfectly clear
Without doubt, therefore, we must
to us on awakening.
of
consciousness as an essential prethe
clouding
regard
liminary condition for the development of delusions.
In paresis, senile dementia, and dementia prsecox, delusions appear in which neither emotions nor disturbances of
consciousness play a prominent role.
The
psychic weakin these diseases,
ness, which is a prominent symptom

seems to favor the development of delusions. But congenital mental weakness shows only a slight tendency
to the development of delusions, and likewise many cases
of senile, paralytic, and precocious dementia run their
course without delusions.

cannot, therefore,
lie
The
real cause for the delusions
in the psychic
weakness of
itself,
but only in the accompanying conditions of excitation,

which permit all sorts of delusional fancies to spring up in
the patient's mind.
delusions originate
pressed moods.
It can
most
be
easily
demonstrated that
freely during heightened or de-

Another source of delusions
may
51
perhaps be found in
those peculiar ideas which in health are accustomed to

occasionally "pop" into our heads, and whose origin we
are unable to account for. While they have no power
over us, for the patient, on the other hand, they bear the
even though soon changed

for others.
They often intrench themselves firmly in
his
thoughts and dominate experience, feeling, and
stamp
of absolute certainty,
conduct.
After this
preliminary
consideration
relative to the origin of delusions,
we
of
all
the facts
are led to the as-
sumption that the essential factor is an inadequate functioning of judgment and reason. In health we are accustomed
to judge all our fancies according to the standard of our
own past experience, and to regard as invention that which
does not conform to our knowledge. The patient either

does not perceive the contradictions between his fancies
and his former experience, or he disregards it and hides it

under assumptions which are even more fanciful. Clearly
the patient has lost, not only the impulse, but the power,
to oppose, correct, or suppress his delusions. The cause
of this disability was formerly sought in the peculiar attributes of the individual ideas.
The doctrine of "mono-
mania," which held that the "fixed idea" was only a

circumscribed disturbance of an otherwise healthy psychic
was based upon this assumption.

The development of delusions is thus seen to be based
on the general disturbance of the entire psychic life. They
are probably incited by emotional fluctuations which transform slumbering hopes and fears into imaginary ideas.
But the fact that these ideas become delusions and acquire
life,
a power which even
the senses cannot destroy,
can only be
explained by an inadequate functioning of judgment, depend-
52
on impassioned emotional excitement, clouding

sciousness, and weakness of the reasoning power.
ent
of con-
The character and duration of delusions differ according to their mode of origin. Those which originate in
change with the patient's mood,
and usually disappear with the emotional disturbance.
Delusions of delirium, which are determined both by
emotional
disturbances
clouding of consciousness and emotional disturbances, are

variegated fantastic pictures recurring in manifold forms,
with
little
or no mental elaboration or coherence.
They
likewise disappear with the clearing of consciousness and

the subsidence of the emotional disturbance. Delusions de-
pending both upon mental deterioration and upon emotional

disturbances do not vanish with the fading of the emotional
states.
rected
They are gradually forgotten, but are never corby reason. Such delusions occur in paresis, dementia
prsecox,
and
senile
dementia.
In these psychoses the
forgotten delusions may reappear for short periods durWith continued moderate
ing emotional exacerbations.
may be firmly held and

even elaborated, as in the paranoid forms of dementia
emotional excitement delusions
prsecox.
Persistent delusions are of
two types, the systematized
and the unsystematized. If systematized, the individual

delusions form a part of a system
i.e. they all center
or
about some one
more definite objects, and whenever new
;
develop they are absorbed into this system.

delusions
are usually expressed in a logical manner.
Such
The unsystematized delusions may ultimately disappear,
as in dementia prsecox, end stages of chronic alcoholdelusions
and
they may become

permanent through frequent repetitions, without systematization, as in the paranoid form of dementia prsecox. The
ism, paresis,
senile psychoses, or
53
progressive and uniform systematization of the delusions

without marked mental deterioration constitutes paranoia
in the strict sense of the word.
In this form the delusions
become the
basis of a thoroughly elaborated, but falsified,

apprehension of self and the environment; but even here
a decided weakness of judgment

monstrable.
The somewhat
probably always de-
is
system of coherent
delusions, sometimes found in paresis and dementia praesimilar
cox, are always of shorter duration.
Practically all
delusions
center in the
either as
self,
self-depreciation (depressive delusions) or as self-aggrandize-
ment (expansive delusions). Among depressive delusions,

those of self-accusation stand closest to the normal life.
Many normal
persons torment themselves with the belief
that they are unlucky. In states of morbid depression

the idea of guilt may be associated with the patient's
every action.
He
believes that he
and deceiving others;

of abominable deeds
deemable,
is
constantly injuring
him as a series
his past appears to
and
terrible crimes.
He
is
an
irre-
by God and
creature, repudiated
consequently about to suffer a fitting
punishment, arrest, the scaffold, the stake, or whatever else
his ingenuity can invent.
unfeeling
damned, and
is
Related to these delusions are the general fears of poverty, loss of work, or some other misfortune about to befall
themselves
this
or
relatives.
form of delusions
In progressing mental weakness

nihilistic, when everynon-existent or less than
may become
thing, the patient included,
is
nothing.
large group of depressive delusions are those
of persecution.
They originate during periods of indispo-
Mistrust and suspicion are

by peculiar coincidences and misinterpreted reNewspaper articles and popular songs contain
sition, discomfort, or anxiety.
excited
marks.
54
references
and even
indirect
insults.
All
assertions
of
and friendship are disbelieved. At this time, also,

there usually appear hallucinations, especially auditory.
The patient sees himself involved in a network of secret
love
and imminent dangers which he cannot escape.

All are joined against him and gloat over his misery.
Men
call after him, whisper to each other, shun him, spit in front
of him, etc.
Food and drink have a peculiar taste, as if
hostilities
poisoned, etc.
Delusions of jealousy also play a prominent rSle. The
patient notices a coolness in marital relations, detects
fond glances and secret signs, finds in letters arrangements for secret meetings. The wife is embarrassed by
unexpected return home, tries to conceal something,

coughs in a significant manner, the room is darkened.
his
Outside some one pounds on the door, a form scurries by

the window, the last child does not resemble its father,
Indeed, these delusions as cited by the patient are
sometimes presented with such good foundation that it is
etc.
difficult to distinguish
them from
ideas of infidelity that are
actually justified. Delusions of infidelity occur principally

in chronic alcoholism and cocainism, but also in senile
mental disorder.
In advanced mental weakness the persecutory ideas
often assume a very fantastic form. Absurd somatic delusions of transformation and witchery, such as telepathy,
magical, electrical, or hypnotic influences, are common
forms. Sexual delusions are especially common, varying
from mysterious sexual excitation to imagined childbirth
during stupor. All these evils may be attributed to any

individual or group of individuals from the neighbor or
husband, to fraternal or political societies.

In hypochondriacal delusions the object
is
some
alleged
55
Harmless physical symptoms are reof

as
signs
syphilis, sexual excess, paresis, etc.
garded
With the onset of deterioration the delusions become
incurable disease.
absurd and fantastic.
Expansive ideas
may
also
be referred to a somatic
Thus, feeble paretics extol their beautiful voice, their
basis.
gym-
nastic dexterity, although they cannot produce a single

musical tone or even stand on their feet. Closely con-
nected with the hypochondriacal ideas are such expansive

ideas as that the excretions are gold, Rhine wine, etc.
Sometimes delusions with a depressive content acquire the

Patients state that they
significance of expansive ideas.
will die at once in order to be translated to heaven ; they
send invitations to their
own
execution, which
is
to be con-
ducted with great pomp.

The delusion of mental soundness, in spite of deep-seated
mental disease, constitutes an absence of insight into the
disease.
This absence of insight is almost universal in

;
many patients not only consider themselves
morbid states
perfectly sane, but remarkably intelligent, as in paresis

The external relations of the patients, the
and paranoia.
social position
and property, are similarly transformed by

Noble descent, close relation to the
expansive delusions.
temporal and spiritual authorities, even association with

supernatural powers, are among the most frequent forms.
With further development the patient becomes the
Presi-
On the other hand, patients

dent, the Pope, Christ, or God.
boast of their untold wealth and vast estates, including
whole continents or the world
gigantic undertakings
fill
itself,
while vague plans of
their minds.
Depressive and expansive delusions are by no means

mutually exclusive.
They may co-exist or follow one
another very closely. The victim of persecutory delusions
56
discovers an adequate cause
of this persecution in exnatural

ceptional ability,
right to great possession or
His
is the result of jealousy or
detention
high positions.
These relations are not the result of logical
intrigues.
elaboration, but rather spontaneous and independent conIn

sequences of the internal condition of the patient.
dementia prsecox the appearance of expansive ideas following delusions of persecution indicates a decided progress
of
mental weakness.
Disturbances of the Rapidity of Thought.

The normal
of
the
association
of
ideas
and
rapidity
concepts varies so
greatly in different individuals, and sometimes even in the
same individual, that it has been impossible to establish a
standard by which morbid deviations can be accurately estimated. We are, however, able to recognize two disturbances
namely, retardation and acceleration of the train of thought.

Retardation occurs even in healthy individuals as the
and mental fatigue. Some unpleasant

It also occurs
emotional states produce the same result.
during the intoxication produced by alcohol, ether, chloro-
result of physical
form, chloral, and to a moderate degree after the use of

tobacco. This disturbance is characteristic of the depres-
and mixed forms of manic-depressive insanity, is

found in the end stages of dementia praecox and paresis,
and in congenital imbecility. Moderate retardation apsive
pears also in melancholia.

Acceleration is less frequent than retardation.
mal
In nor-
produced only by some forms of emotional

excitement, and by such drugs as morphine, caffeine, and
ethereal oil of tea.
In morbid states genuine acceleration
life
it
is
probably never found. In flight of ideas the thought

may appear accelerated, but even here real delay can usually be demonstrated.
is
57
The capacDisturbances of Capacity for Mental Work.

ity for mental work is independent of the rapidity of
be measured by direct experiforms a most important symptom
It is scarcely to
thought.
mentation, although it
In normal
of mental disease.
work
is
determined by
the capacity for mental

the residua of past efforts. These
life
residua condition the increase of capacity, which we call

In morbid states the effects of practice are
practice.
usually lessened and rapidly disappear, particularly in

congenital imbecility.
The capacity
for mental
work stands
in inverse ratio to
Increased susceptibility to fatigw

susceptibility to fatigue.
is very general in most forms of insanity.
find it in
We
exhaustion psychoses, dementia prsecox, congenital imbecility, and paresis, where it is often the first striking
symptom of the disease. In neurasthenia it is often

masked by increased nervous irritability.
Recovery from fatigue is effected by relaxation and
especially
by
sleep.
Melancholiacs and neurastheniacs
recover very slowly from the effects of mental, emotional,

and physical activity. This is the result, in part of diseased mental tone, in part also it results from disturb-
ances of sleep, not only in amount but depth.

It has
been shown that in conditions of simple overwork the sleep
is
depth very slowly, and

of its profoundness in the
light, attains its greatest
an incomplete abatement
shows
morn-
ing.
work is markedly decreased by

It can arise from insufficient intensity of
distractibility.
the goal ideas, from unusual vividness of individual presentations, or finally from an increased susceptibility to
Finally the capacity for
influences.
Inadequacy of the goal ideas is
the
cause
of
probably
distractibility in paresis and dementia
distracting
58
The vividness of individual presentations is seen

praecox.
in the distractibility of acute exhaustion psychoses, and
and probably also
dementia prsecox and paresis. The
increased susceptibility to distracting influences is a reguespecially in manic-depressive insanity,
in excited periods of
lar
symptom
of
neurasthenia, where quite insignificant
forms of irritation
may become
altogether intolerable.
Disturbances of Self-consciousness.
all
The sum
total of
those presentations which form the complex idea of
our physical
consciousness.
mental
life,
and
mental
personality constitutes selfthe permanent background of our

and exercises a characteristic influence on the
This
is
our mental processes. In content as well as

scope, self -consciousness is determined by the experiences of
each individual. It is a familiar phenomenon in dreams
course of
all
may carry on a complete dialogue indeed, one

be
may
completely taken back by some particularly strikApparently in such
ing expression of his interlocutor.
cases the unity of self -consciousness is lost, which in the
waking state permits us to oversee all our thoughts and
that one
inner impulses at once.

Such a dual personality or splitting
of self-consciousness often occurs in mental disease.
Possi-
bly the
first
indications of this are found in those cases in
which sense deceptions appear to the patients as strange
Whenever a patient suffering from delirium tremens overhears some derisive dialogue
phenomena
of external origin.
about himself, or plans of a threatening nature being devised against him, there is no doubt in his mind that
these are of external origin and not the hallucinatory
Unbeknown to
expressions of his own thoughts and fears.
himself he plays the role of two different persons.
Splitting
often observed in dementia prsecox,
where the patients refer to foreign influences and enemies
of self-consciousness
is
59
residing within their bodies, the thoughts and actions of

which they differentiate very clearly from their own. Some
hysterical
symptoms may be
The temporal connections

past
may be
similarly explained.
of one's personality with the
disordered in such a
way
that the
memory
of
life of longer or shorter duration are comIf during any such period of life there has
certain periods of
pletely lost.
been no development, self-consciousness remains on the
same plane that
was at the beginning of the period in

by means of falsificamemory or inferences. The patient depends upon
it
this case the interval is bridged over
tions of
inferences in the interruptions in self-consciousness occurring in clouding of consciousness, sleep, fainting, befogged
and
states,
delirious
conditions,
Korssakow's psychosis where
by
"
disorder of the attention.
and on fabrications
loss of
The
memory
is
in
produced
so-called condition of
"
represents another form of disis a more or less regular alternation of different states in each of which there is
double
consciousness
turbed self-consciousness where there
only for the experiences of similar previous states.

Thus two different personalities are dovetailed, each of
memory
which has at
disposal only a part of the total experience

of the individual. As a rule, one of these personalities
its
belongs to an earlier stage of development than the other,

and consequently does not possess all the skill and knowlSometimes there takes
edge that the other commands.
place a reversion to a particular period of the individual's
past life, which has been conspicuous because of certain ex-
This condition, called ekmnesia by the French,

be induced experimentally by hypnosis, and is charac-
periences.
may
more
especially of hysterical insanity.

Self -consciousness is no fixed mental construct,
teristic
changes continuously with experience.
but
it
So disease processes
60
The
are able to falsify it, though not in like manner.
The alteration of self-consciouscause of this is not clear.
ness in the depressive stages of manic-depressive insanity
is often very striking, while in melancholia it may be
insignificant in spite of the extensive delusional conception
of the environment.
Also in delirium tremens the patients
have the most fantastic experiences without suffering any

-alteration of self-consciousness.
Since the most extensive
alterations of self-consciousness occur in paresis, dementia

prsecox, and in manic-depressive insanity, the hypothesis
sis
plausible that this disease
symptom
is
related to dis-
On
the other hand, we are accustomed

to ascribe disturbances of the will in large measure to the
turbances of
will.
character of the psychic personality.

The particular form of the falsification of self -consciousness
is
determined by the morbid disposition.
Thus
in
manic patients the peculiar condition of self-consciousness

leads to the development of expansive ideas, which in reality
are nothing more than a playful expression of the emotional
elation.
In the depressive and stuporous phases of manicdepressive insanity the patients become not only depressed
and abject, but they even feel physically altered
turned
to stone, dead, and transformed into other individuals,
such as the devil and animals. Similarly the paretic in
accord with his expansive and pessimistic ideas comes to

believe that his body is variously altered.
In dementia
pnccox this condition, although present, is less pronounced,

and in contrast to paresis and manic depressive insanity is
not infrequently associated with ideas of some sort of external influence which produces the alteration.
In paranoia,
the disturbance of self-consciousness is very slight and confined to the
abilities.
delusional overestimation
of
the
patient's
61
In advanced deterioration, self-consciousness ultimately

In dementia prsecox and paresis this is the
disappears.
usual terminus of the mental
life.
emphasized, however, that this
is
It is to
be especially
not the result of deterio-
cases,
but a special symptom of these diseases. In some

on the other hand, even when the store of ideas is
much
impoverished, the patient
ration,
sciousness
This
is
still
and can give an account
particularly
common
retains his self-con-
of his
in epileptics.
own condition.
Even in pres-
byophrenia, where, on account of the marked disturbance

of attention, experiences disappear entirely from memory
and are replaced by the freest invention, self -consciousness
is
retained.
6.
DISTURBANCES OF THE EMOTIONS
Every sensory impression which sustains any intimate reman's welfare is accentuated in consciousness by
a concurrent feeling of pleasure or pain, depending on its
apparent tendency to advance or retard the general aims of
lation to
Therefore, the feelings are a direct indication of the

attitude of the ego to the perceptions of the external world.
life.
According to Wundt, one can distinguish three opposite

states of feeling, which rarely exist alone, but almost always
accompany mental processes in various combinations;
namely, pleasure and displeasure, excitement and calmness,
perhaps preferably retardation, and finally tension and

Disturbances of the emotional life often form
relaxation.
the
first
striking
symptom
of disease.
But the recognition
and estimation of these disturbances is difficult, because

we lack an adequate normal standard. Even in health the
emotions show marked personal peculiarities, closely allied
to the abnormal.
Diminution and Increase of Emotional
Irritability.
diminution of the intensity of the emotions

and most frequent disturbance. In normal
in the environment
is
reflected in
tuations of his emotions.
more or
is
The
their simplest
life
one's interest
less intense fluc-
Diminution of these emotional
accentuations indicate indifference toward the impressions

This is characteristic of most forms
of the external world.
mental deterioration, of which it is one of the first and

most striking symptoms. Emotional indifference may be
of
marked even when external impressions are well apprehended
63
This striking disproportion between disturbances of the intellect and the emotions is most pronounced in dementia praecox. In paresis, on the other hand,
and elaborated.
mental elaboration
is
disturbed to a
much
greater degree
than the emotions.

All phases of the emotional life seldom suffer equally.
Naturally the patient loses most easily those feelings which
are not directly connected with the changes of his own ego,
but are related to the more remote, external world, and

further those feelings which have lost their sensory proper-
and are aroused only through the higher mental processes

as concomitants of general ideas and moral principles. The
active interest of the patient becomes exclusively selfish.
ties
He
loses all pleasure in
mental work, and
all feeling for
higher claims of propriety, morality, and religion.
the
Considera-
tion for his environment, his family, relatives, and finally for
mankind in general, has no influence on his conduct. He
loses the sense of
shame and lacks
all
comprehension of the
conventions of social intercourse.
Emotional deterioration
symptom
of
very often the first striking

dementia praecox, and advances with the
is
progress of the disease.
It regularly occurs in senile de-
mentia, and sometimes
an early symptom
is
of paresis.
In
appears, also, in simple senility. Emotional deterioration is also prominent in many forms of
its
simplest form
it
"
moral imcongenital imbecility, especially the so-called
in
which
the
a
certain shrewdness
becility/
patients show
7
in the
attainment of
selfish
advantages which often conceals
the real severity of the disease.

Lower or sensuous feelings possess a greater momentary
intensity, but are at the same time more transitory than
the higher moral aesthetic sentiments, which accompany and
determine our thoughts and actions throughout our entire
64
life,
and act as checks on sudden emotional impulses
of the
lower order.
The absence
of these checks in imbecility gives rise to
sudden, but transitory, outbursts of passion. Without a

firm foundation for the emotional life a mere trifle, a word,
the tone of the voice, suffices to plunge the patient from the
most
blissful self-complacency into
spair.
This
is
The emotional
of
an
especially prominent symptom in paresis.

indifference characteristic of the end stages
dementia prsecox
tional ebullitions.
indifference
is
the most profound de-
is
regularly accompanied by such emocharacteristic of emotional
A permanent
lack of insight.
The retardation
of depressed
manic-depressive patients sometimes presents a
superficial
similarity to the emotional indifference of the deteriorated,

but the former realize their condition, and often complain
that they are forsaken and desolate.

of the emotions is characteristic of
An
especial vivacity
women and
children.
The emotional
states are highly unstable and are readily

by momentary conditions. The great ease with
which vivid feelings appear and disappear is characteristic
influenced
of
some
lies
of the psychopathic states.
the syndrome of hysteria.
This condition under-
In this disease ideas have
such an intense emotional tone that a powerful influence is

exerted not only over the will but also over such physical
processes as are, in general, not under voluntary control;
as, breathing, circulation, pulse, muscles of the bladder,
rectum, and hair, secretions of the glands, as well as the
accuracy of movements and the clearness and intensity of

sensations.
temporary increase of the emotional irritability is seen

in some of the excited stages of paresis, catatonia, and in
manic phases
Since the
manic-depressive insanity.
vividness of the temporary emotional state forces the
of
65
restraining influence of the higher feeling completely into
the background, this condition
is
accompanied by the im-
change of mood. A similar condiportant phenomenon

tion is observed in the intoxicated individual, in whom
the exuberance of
abrupt change of
is so often accompanied by
In this condition it is possible
feeling
mood.
one to influence markedly the tone of feeling of the

patient except in catatonic excitement, where negativism
for
prevails.
Morbid Temperaments.
The same experience may arouse
wholly different mental attitudes in different individuals,
according to the constitutional tendency to certain tones of
Because of the
feeling, the temperament of the individual.
infinite variety of
the combinations of feelings it is almost

all the different types of tempera-
impossible to describe
In the morbid
ment.
field this difficulty is
even greater;
hence we must content ourselves with a brief sketch of only
some
of the forms.
Since displeasure exerts in general a stronger influence

over our mental life than pleasure, we would expect to find
This
it playing the more prominent role in morbid states.
increased susceptibility to the unpleasant leads to a tendency
all of life's experiences only that which is
to discover in
unpleasant. The past is crowded with sad experiences and

the future a source of anxiety. The individual's own wellbeing is the centre of his thought, and every insignificant
regarded as a sign of threatening disease. The

dejection which in normal life accompanies sad experiences
gradually wanes, but in disease even a cheerful environ-
ailment
ment
is
fails
tensify
to mitigate
sadness, indeed,
it
may even
in-
it.
Whenever morbid sadness is accompanied by an inner

tension, the emotional state becomes one of apprehensiveness.
66
The patient
a lack of security and freedom, together

with a lack of confidence in his own ability. He awaits
feels
with apprehension the outcome of every act, and doubts its

In this state his own physical
justification and fitness.
a very fruitful source for the development of
There develops a self-torture and an
all sorts of doubts.
of
liability. This type of feeling furnishes
exaggerated feeling
condition
is
the basis for the morbid fears to be described later, and also
often seen in the incipient stages of melancholia.
is
When
this increased susceptibility to the unpleasant is
associated with excitement, there exists what is known as

an irritable disposition. This is characterized not only by a
general tone of displeasure toward everything, but
by an
emotional excitement which demands expression and is

held in check only by a constant struggle. This lack of
means a persistent variation of the emotional equilibrium and a condition of instability with occasional violent
control
outbursts of feeling, which sometimes take the form of

despair
and sometimes
chiefly in congenital
especially
in
the
of anger.
Despair
neurasthenia, while
epileptic
and
is
encountered
anger
hysterical
is
found
constitutions
(Irabundia Morbosa).
Morbid sensitiveness to the outer world does not always

lead to passionate outbreaks, but sometimes produces that
type of temperament termed seclusiveness. Seclusiveness is
not accompanied by that passionate feeling of anger that

goes with the defiance of a normal individual, but it indicates a sort of shrinking from the impressions of life with a
less clear consciousness of one's own insufficiency.
more or
Conversation with strangers, entering a new environment,

unusual demands, and difficulties appear to a patient as
unsurmountable obstacles. This condition underlies the
conduct of
many
of the merely
"
"
peculiar
individuals.
67
history of such peculiarities often antedates the outset of
dementia prsecox.
The pronounced feelings of pleasure are found in those

happy sunny dispositions that are always in good humor,
see things on the best side, and are most enthusiastic.
Associated with this state there
often a pressure of
activity, which incites the individual to various changing
unsuccessful pursuits; a combination, which also exists in
is
Another modification of the emotional
Here
life is
fanaticism.
there
develops prominently types of feeling,

of
a
especially
religious and sexual nature, which control
thought and action. These individuals may exhibit the
also
most extraordinary feeling of happiness that rises above all

external sadness and adversity. The hysterical constitution
arises from this sort of a basis.
Closely related to these
fanatics are the morbid swindlers with their great love for
adventure, and for the exciting and the unusual. The

exaggerated joy in their own inventiveness forces all deliberation into the background.
exist here.
Hysterical
symptoms
closely allied disposition is morbid frivolity,
also
charac-
by superficiality of the emotions. Here there is

an increased susceptibility to superficial distractions while
serious things are not taken seriously.
Life in general is
regarded as a joke. Associated with this morbid frivolity,
which is an essential element in some forms of imbecility
and weakmindedness, there is regularly a defective development of the higher feelings, a selfishness and instability of
terized
the
will.
A common characteristic of this condition of frivolity is an

exaggerated
self -consciousness.
and work appear to them
in
an
The
patients'
own
abilities
especially favorable light.
68
These patients not only grossly overestimate themselves, but

have a corresponding lack of sympathy for others. This
selfish
onesidedness of the tone of feeling exists in
many
born criminals, also in the pseudo-querulants, where it is

It is probably also a
combined with great irritability.
favorable soil for the development of genuine querulants
and perhaps the allied forms of paranoia.
Morbid emotions are distinguished

Morbid Emotions.
from healtliy emotions chiefly through the lack of a sufficient cause, as well as
by
their intensity
and
persistence
furthermore the tone of feeling usually corresponds to some

of the well-known mixed feelings.
Even in normal life
moods come and go
in
an unaccountable way, but we are
always able to control and dispel them, while morbid moods

defy all attempts at control. Again, morbid emotions sometimes attach themselves to some certain external occasions,
but they do not vanish with the cause like normal feelings,
and they acquire a certain independence.

By far the commonest form of the unpleasant morbid
emotions is /ear, which may perhaps be regarded as a combination of a feeling of displeasure with an inner tension.
It influences the whole physical and mental condition more
profoundly than any of the other emotions. The inner
exhibited physically by the facial expression,
bodily attitude, convulsive action of the muscles, in a moan
or an outcry, in an act of defence or escape, in attacks on
tension
is
the surroundings or the patient's own life. Besides this

there is apt to be precordial oppression, palpitation, pallor,
increased respiration, tremor, and sometimes perspiration
and an increased
desire to urinate
and
defecate.
In morbid
usually without an object at first. The

afraid without knowing why, and indeed are
conditions fear
is
patients feel
often well aware that their fears are groundless.
In the
69
constitutional psychopathic states the indefinite fear often
assumes peculiar forms, as the feeling of homesickness and

the like. In acute mental disturbances the indefinite anxious forebodings
become
fixed into
more or
less
definite
Extreme
fear, like all extreme emotions, is always

a
accompanied by
clouding of consciousness.
Fear is not maintained at the same intensity for any
fears.
considerable length of time, but shows remissions, and

aggravations, the latter especially at night. Fear is most
pathognomonic of melancholia of involution, where it is

seldom absent. It occurs frequently in depressive forms of
manic-depressive insanity, but may be absent. It occurs
also in the befogged states of epilepsy, in delirium tremens,
and in the beginning of catatonic excitement. Paresis
sometimes presents fear in
its
most extreme form.
A large group of disturbances characterized by fear is

found in the so-called compulsive fears, phobias. These fears
are sometimes associated with some personal experience or
idea which has given rise at some time to fear. In the
lightest forms such fears are encountered in normal individuals, but here they lack the persistency
and obtrusive-
ness which characterize the phobias.

The compulsive fears are characteristic of
some forms
of
the psychopathic states, but
may appear transitorily in

These
compulsive fears include
the fear at the sight of or contact with certain objects, as
also the fear of being alone
of
the
fear
crowded rooms, of open or
streets,
closed doors, etc. (see pp. 499-503). These patients are
spiders, knives, needles, etc.;
on deserted
tormented by the idea that their clothes do not fit properly,

that they themselves are soiled or poisoned by contact with
others, that they might have swallowed needles or fragments
of glass, that in tearing up any scrap of paper they might
70
have destroyed valuable papers,
Other closely allied

disturbances are the feelings of discomfort which arise
whenever individuals are compelled to come into any sort of
relations with others, as in erythrophobia, morbid blushing.
etc.
While fear has been designated as sadness with inner

tension, simple dejection is defined as sadness with inhibition ; in other words, anguish with a feeling of insufficiency.
The basis for this emotional state is found in the sorrow
which impresses
arising in the person himself,
itself
upon
the experiences of life. As the result of this, the

entire past seems but a series of misfortunes and failures;
all of
the present
is
troubled and dark, and the future dubious;
sad thoughts and forebodings
all sorts of
arise,
which
may
self-reproach and persecution,

the feeling of desolation. Patients
lead to delusional ideas of
but the most painful
is
pleasure nor sorrow; indeed, they do not respond emotionally to any of the impressions of the outer
One patient expressed himself by saying that he
world.
"
To be sure I see things well
like a cinematograph.
felt
I
feel
don't
them."
The normal pleasure in
enough, but
feel neither
mere existence gives place to a feeling of weariness of life.

The alteration of the tone of feeling which is characteristic
of some of the circular depressive phases of manic-depressive
insanity as a rule
accompanied by a retardation of thought

and action. The patients regard their condition as the most
agonizing; they feel as if they were inwardly dead, had
become
is
heartless
entertain ideas
and morally
of
physical
desolate.
They frequently
In reality these
as may be judged from
alteration.
patients are not without feeling,

their occasional attempts at suicide.
The retardation may
suddenly give place to excitement.

Sadness with excitement is occasionally observed in manicdepressive
insanity,
occurring either as an independent
71
phase or as a transitional stage between different phases

In this case the mood is sometimes sad,
of the disease.
sometimes anxious or passionate, the patients expressing

themselves in wailing and moaning, in states of anxiety, or
in outbreaks of irritability.
The latter form is particularly
The
common.
patients are fretful, discontented, at variance
with themselves and their environment, and annoyed by

trifles.
They grumble and growl in the most intolerable
manner and show outbursts
An emotional state
provocation.
conceit
on the slightest
sort combined with
of passion
of this
and an attempt to be
sarcastic is
exaggerated
sometimes encountered in syphilitic insanity. Many of the
emotional states of the hysterical patient exhibit a mixture
of sadness
and excitement with passionate
irritability.
The
epileptic presents a special type of emotional disturbance namely, a simple dejection with a feeling of weariness of life. Occasionally it is associated with a feeling of
;
but usually there
is a sort of homesick feeling

with an indefinite yearning and inner restlessness, which
inhibition,
leads to suicidal attempts, indulgence in alcohol, or aimless

wandering. Yet irritability with sudden violent outbursts
In the epileptic bequite common.

fogged states a tense anxious feeling predominates, someof great intensity
is
times combined with great irritability. Furthermore in all

of these emotional states there may be a mixture of a sexual
or ecstatic feeling of pleasure.
The morbid feelings of pleasure are less frequent than

those of displeasure. They occur especially in alcoholic
intoxications and alcoholic psychoses, manic-depressive insanity, paresis, dementia praecox, morphin and cocain intoxication.
The
enterprise
and
from alcohol probably originates in
of the release of motor impulses in the brain,
feeling of increased strength, enthusiasm,
which
the facilitation
results
72
while further action of the drug causes irritability, restlessIn the manic forms of manicness, and aimless activity.
depressive insanity in which there
of pleasurable feelings, irritability,
the emotional disturbance
This belief
origin.
perimentation.
the disorder.
stamp
of a
is
is
a similar combination
and pressure of activity,

believed to have a similar
substantiated by physiological exIn both conditions there is no insight into

is
The emotional
attitude in both bears the
wanton happiness, and self-confidence
is
greatly
increased.
The high
spirits so characteristic of the chronic alcoholic
represent another type of morbid feeling of pleasure, and

are designated drunkard's humor. The same state may
exist in delirium
tremens where, however,
a sort of concealed
fear.
Its origin
is
mingled with
unknown, but may
it is
from the drunkard's insusceptibility to

however,
humiliation and his moral apathy to vice. In paresis the
pleasurable feelings are apt to be marked, especially the
In this disease, however, these feelfeeling of well-being.
arise
ings often exist unaccompanied by motor excitement, and

in spite of the expansive ideas, there is absent the lack of
and fresh energy that is so characteristic of the

manic exhilaration. In the later stages of paresis the feel-
restraint
ing of well-being subsides to a silly thoughtless happiness

irritability which is found in the
without a trace of the
In dementia prsecox, during

the excited stages, pleasurable feelings take on the form of
a silly, purposeless hilarity and exuberance with outbursts
later stages of the alcoholic.
of silly laughter, which, in contrast to the hilarity of the

manic forms of manic-depressive insanity, seem to bear no
and environment.
Cocain, morphin, tobacco, and the bromides also produce
In tobacco smoking
characteristic feelings of well-being.
relation to the patient's ideas
73
the feeling of agreeable contemplation is due purely to a

soporific effect; the bromides produce a feeling of well-
being by relieving a state of inner tension. The feeling of

ecstasy, which occurs especially in epilepsy, and sometimes
in hysteria, seems to be very similar to the dreamy state
which follows opium smoking. The origin of morbid feelings of pleasure is very difficult to determine, both because
they may arise from a great many different disturbances,
sometimes somatic and vaso-motor, sometimes primarily

emotional, and sometimes intellectual. Different types of
feeling
may
exist at the
same time or may succeed each
other rapidly, as seen in the mixture of fear and humor in

the alcoholic and of ecstasy and anger in the dreamy states
of the epileptic.
Disturbances of General Feelings.
General feelings are
those emotional states which stand in close and inviolable

relation to self-preservation, such as feelings of fatigue and
hunger. They are to be regarded as admonitions, which
gradually develop out of the experience of countless generations into involuntary and instinctive impulses.
In ordinary
life these feelings inform us of our bodily needs, and they
imperiously exact actions adapted to the circumstances.

The performances of these actions can usually be inhibited
by conscious
self-denial;
although often only by means of great

the feelings themselves are, on the contrary,
volition,
only thoroughly silenced

in some way or other.
when
the indicated need
In normal
life
is
relieved
a general feeling
may disappear when we pay no heed to it. We are able

to overcome weariness when work demands our strength;
hunger abates when we are unable for a long time to satisfy
it.
When at last we have the opportunity to attend to our
needs for rest and food, we miss at first the painful weariness and hunger which makes the restoration of our strength
74
so easy.
Only when we have rested
for
some time do we
again experience a feeling of weariness, while hunger gradually returns as soon as we begin to eat.
In normal life the performance of mental and physical
The basis
is accompanied by a feeling of pleasure.
for this experience lies in the fact that the formation and
work
maintenance of personality depends upon activity. If this

feeling of pleasure is absent, one regularly develops a form
This is the form of ennui that develops from
and soon forces one to some sort of endeavor. To
a normal man enforced idleness is most irritating. Among
the insane this form of ennui is usually absent because
of ennui.
idleness
the patients, even although unemployed, are completely absorbed in their own morbid mental processes. The appear-
ance of this ennui in a patient may, therefore, be regarded

as a favorable sign; yet one must be cautious not to confuse
it either with the feeling of discontent that is often referred
to
of
by the dejected patients as ennui, or with the pressure

The complete absence of
activity of the manic patients.
ennui in dementia prsecox is a very important symptom.

Here there is a complete loss of volitional impulse from
which the desire for activity takes its origin. The patients
can in spite of clear consciousness lie abed weeks and
months without in any way becoming uneasy at the lack
Their lack of ennui always indicates a profound disorder of the mental life, and especially accomof activity.
panies progressive deterioration.
A wholly different significance attaches to that unpleasant

which accompanies
excessive exercise as a sign of warning. This form of
weariness generally indicates in a normal individual an
actual need for rest; in other words, fatigue.
Patients
sometimes fail to show their fatigue, although there is real
feeling often designated as weariness
75
need for rest. In many excited states, especially in manic

forms of manic-depressive insanity, there is often a complete absence of fatigue in spite of the fact that the patients
are exhausted
The
by continual
restlessness.
feeling of hunger is similarly disturbed in these
psychoses.
In paretic and catatonic patients there
is
same
often
a senseless voracity, although the well-nourished patients

have no need of such an amount of nourishment. In the
constitutional psychopathic states and in hysteria, without
any perceptible relation to the state of bodily nutrition,
there may be a prolonged absence of the feeling of hunger,
which
is suddenly replaced by gluttony.

Severe disturbances of the feeling of nausea are almost
always signs of a far-advanced deterioration. Such patients

consume the most disgusting things,, even their own dejections.
Not infrequently they swallow
nails, stones, pieces
of glass, or animals, not only with suicidal intent, but con-
stantly overpowering their nausea from pure greediness.

These patients also lose those feelings which cause us
aversion at the mere contact with filth or dirt and impel
one to keep clean, not only the body, but the whole environment. They recklessly soil themselves, even intentionally, with their own food, their own saliva, urine, and
even feces.
The feelings of physical pain are often abolished. In

conditions of excitement, especially with intense fear, even
severe injuries produce no sensation at all, although conSuch patients pluck out
their tongues or eyes, cut open the abdomen, etc., deeds
which would be utterly impossible for a man with a normal
sciousness
may
sense of pain.
be perfectly
clear.
This insensibility to physical pain is often

found in demented patients, especially in paretics, in whom,
to be sure, the destruction of the nervous conducting paths
76
is
an
The absence
the hysterical and
essential antecedent.
to pain encountered in
of the sensibility
epileptic patients
in
these
conditions
the threshold
essentially different;
of pain only appears to be raised.
is
There
a group of feelings which pertain to the
is finally
maintenance
of the race rather
namely, the sexual feelings.

patients the feeling of shame
than to self-preservation;
Among bewildered and excited

may pass wholly into the back-
ground; yet one sometimes observes distinct evidences of

the feeling of shame in the great excitement of manicdepressive cases
sexual feelings.
when it is not overpowered by

The rapid disappearance of the
increased
feeling of
shame even without sexual excitement is a striking symptom of dementia prsecox. Such patients denude themselves recklessly,
and masturbate
also tend
to
speak shamelessly about sexual matters,

persistently and openly. These patients
employ obscene language
(copralalia)
and
gestures.
Sexual feelings in mental disease are either increased,

Sexual indifference occurs in many
abolished, or perverted.
forms of the constitutional psychopathic
states,
ticularly in hysteria, also in morphinism.
An
sexual excitability which

,
is
more frequent,
is
and par-
increase of
found in some
idiots, but in a more pronounced degree in dementia praecox,

and also in the excited stages of paresis, the manic forms
of manic-depressive insanity,
and
in senile dementia.
Per-
those in which sexual feelings

occur exclusively in connection with persons of the same
sex, associations with certain objects, or accompanied by
verted sexual feelings are
brutality (see p. 92).
DISTURBANCE OF VOLITION AND ACTION
D.
ALL
disturbances of the psychic
life
find their final ex-
pression in volition and action. The idea of a definite aim

(some change either in ourselves or our environment) forms
the starting-point of a volitional act. This idea is accompanied by feelings which are converted into impulses for
The
the attainment of that aim.

is
is
direction of
any action
determined, therefore, by an idea, while its performance

determined by the intensity and the duration of the
accompanying feelings.
Morbid disturbances of volition manifest themselves in the
most varied ways: the energy of the volitional impulse
can be diminished or increased; its release facilitated or
impeded; or the direction can be modified by external or
internal influences; morbid impulses can forcibly suppress
the normal will; or natural impulses can assume morbid
forms; finally, the conduct of the insane is naturally influenced by all those disturbances which occur in other
spheres of their mental life, although the volitional process
itself presents no disturbance.
Diminution of Volitional Impulses.
pension of volitional activity is
It is
The complete
termed paralysis
produced by extreme fatigue, profound alcoholic
toxication,
and
sus-
of the will.
in the narcoses of chloroform, chloral,
in-
and
characterized by an absence of energy.

Ordinary impulses find no issue in action, while even the
most powerful incentives of personal well-being and moral
morphin.
claims
fail
It
is
to
influence
the patient.
77
more or
less
78
complete paralysis of the will occurs in the end stages of

progressive mental deterioration senile dementia, dementia
:
and
prsecox,
paresis.
diminution of personal
This
is
characterized by a
initiative,
marked
except in gratification of
and vegetative impulses, such as
the lower,
selfish,
greed,
If left to themselves, the
gluttony, and sexual desire.
patients are content to sit around, inactive, displaying very
animation and staring vacantly into space. In dementia prsecox it can often be shown that the patients have
little
not lost the voluntary control of their actions, but normal

In the end stages of
incentives fail to influence them.
deterioration
the
only movements are
involuntary
and
Similarly, defective volition appears in congenital
reflex.
imbecility as the result of defective development.

Increase of Volitional Impulse.
The universal indication
of the increase of volitional impulse is motor excitement. But
we are really justified in speaking of an increase of volitional
impulse only when there is a marked disproportion between

the intensity of the excitation and the importance of the
In alcoholic delirium, for example, we find marked

unrest which cannot be explained by the patient's delumotives.
sions, hallucinations, or emotions,
but must be referred to a
morbid motor excitation. Patients will not remain in bed,

show a pronounced restlessness, and constantly busy themselves as if employed in some occupation.
In alcoholic intoxication, increase of volitional impulses begins with simple
loquacity, and increases to brawling, screaming, and aimless
activity.
In chronic cocain intoxication (see
p. 210) there
develops a peculiar motor excitability which seems to form

a transition to the morbid pressure of activity which is a
characteristic
p. 387),
paresis.
and
is
symptom
of manic-depressive insanity (see
sometimes found in exhaustion psychoses and
79
In the lighter hypomaniacal disturbances this pressure

form of general instability and busy-
of activity takes the
ticulation.
Such
and a tendency
to animated gespatients collect all sorts of useless things,
ness, great talkativeness,
begin countless undertakings which they never finish, and,

when unrestrained, travel aimlessly about. In more marked
excitement the goal ideas become more and more inconstant, and one can hardly detect any purpose at all in their
ever changing, incoherent activity. Patients scream, laugh,
sing, dance, disrobe, tear their clothing, smear themselves,
wash in their own urine, destroy everything they can

and pound incessantly with their hands and feet.
reach,
Catatonic excitement furnishes a picture essentially different from that of the manic pressure of activity.
In
the manic excitement,
all
impulses lead to more or
purposeful actions, though they might at
first
less
appear pur-
In catatonia, on the contrary, we

poseless and senseless.
have to do with movements which at most have no definite
aim.
Although the characteristic excitement in catatonics
more moderate, the movements are entirely purSuch patients make grimaces, contort the body,
poseless.
run about, clap their hands, and utter a succession of senseless noises.
These movements are not pure volitional acts,
as there is no antecedent idea of their purpose.
Patients
themselves often assure us that they do not know why
is
often
they perform such absurd antics.

The strength
Impeded Release of the Volitional Impulse.
and rapidity with which a volitional impulse is converted
is dependent, not
only on its own
on the resistance which it has to overcome.
into action
also
and
fear
intensity,
but
Thus, fright
present obstacles to the realization of our

which
can be overcome only by the most strenuous
intention,
exertion of the will.
may
80
The psychomotor
retardation,
which
is
the most important
disturbance in the depressed states of manic-depressive insanity, is probably due to a similar increase of resistance.
Such patients require special exertion of the will for almost every movement. All the actions are characteristically
slow and weak, except when a powerful emotional shock
breaks through the resistance. The retardation may become less pronounced under the influence of continued effort.
In severe cases independent volitional action is almost imIn spite of every apparent exertion, the patients
possible.
cannot utter a word or at best answer only in monosyllables,
and are unable to eat, stand up, or dress. As a rule they
clearly recognize the enormous pressure lying upon them,
"
stupor
is usually applied to these disturbances, but they are only
superficially related to the stupor of catatonia.
which they are unable to overcome.
The name
"
In catatonic stupor the release of movements in itself is

difficult, as action is occasionally both rapid
not rendered
and powerful. But every impulse is almost immediately

followed by the release of an opposing impulse which prevents the consummation of the act. Thus, we often see the
desired
movement begin
all right,
but
it is
immediately
in-
terrupted and extinguished by the opposing impulse. Here

the impulse is not hindered by internal resistance, but is
simply quenched by a counter impulse. In contrast to the
retardation, in which there is a continuous hindrance, one
As soon as the blockmight refer to this as a blocking.
ade is raised, the counter order disappears, and the action
proceeds without the slightest difficulty.

As a result of this blocking of the will
many
reactions
which normally occur without special act of volition are

suppressed at their inception. The patients will not look
up when accosted, or shake hands when the hand is proffered.
81
one threatens them with a knife, or pricks the eyelid, they

may perchance shrink away, but they never make any wellIf
directed effort to protect themselves;

in the
most uncomfortable
positions,
they continue to lie

will sit for hours
and
when by taking a couple
of steps they could

the
persistent holding open of
Possibly
the eyelids, the regular swallowing of saliva, and the retention of urine and feces may be explained in this way. The
in the sun,
reach the shade.
whole attitude of the patient becomes strained and unnatural.
In blocking of the will there is no lack of impulses, but

rather a balance of counter impulses. Hence we do not
find the lassitude characteristic of retardation but a rigid
which discloses the play of opposing influences.

Movements take place with an excess of tension which extension,
tends almost equally over all associated groups of muscles:

the resulting action depends on relatively slight preponder-
ance of one group of muscles over the opposite group.

Hence both station and movement appear tense and stiff.
Occasionally the relative strength of impulse and counterimpulse varies, sometimes one and sometimes the other
gaining the upper hand. A movement suddenly stops and

then just as suddenly begins again. It proceeds by jerks
and
is
ness of
awkward and clumsy.

all this
Possibly it is the consciousthat

leads to the innervation of
opposition
more remote muscle groups. The entire limb is apt to

come into play for the simplest movements, which thereby
become ponderous and indefinite.
Facilitated Release of Volitional Impulses.
Both the
impressions of the outer world and our inner experience
develop in us continually more or less tension of the will,
which tends to relieve itself in the most varied expressions.
Part of these operations are independent of voluntary con-
82
The
greater part of them, however, are subject to

inhibition through voluntary effort. The ease with which
trol.
converted into action depends upon the development of the inhibitions which we control. Our mental
impulse
is
development means in general an increase of inhibitions.
The
child reacts immediately, while
growing self-control
man
to suppress numberless impulses, before

they develop into action. The female sex with its heightened emotional irritability tends to remain on the plain of
enables the
the child.
The
restraining power of the inhibitions naturally depends

the strength of the impulses and the intensity of the
on
emotional state, from which they originate.
On
the other
hand, there are well-recognized influences that facilitate

the release of impulses and thereby lessen the resistance to
the conversion of an impulse into action. This operates to
a greater or less degree in all forms of psychomotor activity.
Whenever movements are continued there arises a

degree of excitement which means a diminution of
certain
inhibi-
has already been pointed out that morbid

Indeed,
inhibition is gradually reduced by activity.
Still more evition.
dent
it
is
the increase of excitement in manic
and catatonic
patients when their restlessness is not restrained. An unrestrained discharge of impulses always makes it more difficult for the patients to control themselves.
A
by
most
significant diminution of inhibition is
Ether and cocain have a similar
alcohol.
in the acute
The
intoxications.
facilitated release of volitional impulse is a constant
symptom
in
in hysteria.
leaves
and chronic
produced
both
effect
little
some forms
of
morbid constitution, especially
In this disease the intensity of the emotions

room for the reasoned action, hence these patients
sometimes suddenly find themselves performing strange and
83
incomprehensible acts, as thieving, cheating, and self -mutilation, apparently at variance with their intention.
The motives of
Heightened Susceptibility of the Will.
action have two sources: external stimuli; and those
relatively constant principles of action
which
arise
from
within rather than from without, and render the individual's

conduct more or less independent of his surroundings. The
by these general principles is lacking only

and unstable individuals. In diseases this con-
control of actions
in children
trol is lost in
weakness of the
and
excitability,
in
conflict
will,
with
increased psychomotor
overwhelming morbid
impulses.
Weakness
of will is
found in
all
forms of imbecility, where
the fixed principles of action are lacking. There is no inThe chief characternal unity or consistency in conduct.
a hypersuggestibility, through which the patients

become the prey to every accidental influence. This con-
teristic is
purest form in paresis. Similar

phenomena are induced through suspension of these fixed
principles of action by means of hypnotism.
dition
is
found in
its
Transient hypersuggestibility is found in catalepsy, where

often the limbs of the patient will remain in any position
in which they are placed until, as the result of extreme
muscular exhaustion, they tremblingly obey the laws of

In this condition there is often found a moderate,
gravity.
but constant, muscular resistance called cerea flexibilitaSj
in
which
it is
possible to
mould the limbs
into
any desired
Less often patients are found who will repeat for

position.
some time any simple movement, once started, or who will
laboriously imitate everything done in their presence
praxia.
In
echolalia
the
echo-
patient involuntarily repeats

every word he hears, although at the same time giving
evidence of considerable elaboration of impressions by his
84
Indications of these symptoms, especially cerea flexibilitas, are occasionally observed

in the most varied diseases, such as hysteria, epilepsy,
ability to solve simple problems.
manic forms
of
manic-depressive insanity,
paresis,
and
alcoholism; but the whole group of symptoms is most

pronounced in dementia prsecox, especially the catatonic
form.
Distractibility of the will is
ideas into action.
a morbidly easy translation of
accompanies heightened susbut is differentiated from it by a
It usually
ceptibility of the will,
reaction to internal as well as to external stimuli.
It is
to conduct what the distractibility of the attention
is
intellection,
and
effectually prevents
control of action.
Sudden
all
permanent
to
volitional
resolutions are half carried out
only to yield to new ones. The patients are wholly under

the influence of the environment, whether good or bad.
Distractibility of the will is found in certain conditions of
It accompanies hystemanic and delirious excitement.
ria and some forms of imbecility as a permanent personal
characteristic.
Interference and Stereotypy.

The carrying out of any
in
act
is
determined
simple
general
by the goal idea. Since
our movements are usually governed by the principle of
economy, we seek to reach the goal with minimum expenditure of strength and time. In case this principle is clearly
transgressed, or if the act is clearly inappropriate, we have a
disturbance of conduct which is provisionally called inter-
which the correspondence between intention and

accomplishment is interfered with by the interpolation of
ference, in
incongruous impulses. Here, apparently, incidental impulses break into the natural flow of conduct. A similar
condition obtains in the blocking of the will. One may
regard the blocking of the will as a special case in which the
85
incidental impulses are directly opposed to the original impulses; then interference would be regarded as a crossing
by the incidental impulses in various

The blocking of the will would then be only
directions.
a special form of the general disturbance which may be
Both
described as a crossing of the voluntary impulses.
of the original impulses
symptoms belong to catatonia.

The incidental impulses may influence action in many
The simplest form is probably seen in the
different ways.
reiterated repetition of chance impulses.
Normally every
is
aim
is
forced into the
as
the
as
soon
realized,
impulse,
background by other impulses. But where the pursuit of

any definite aim is disturbed and there still remains a
general pressure of activity, any impulse once released has
a good chance to be repeated as long as the active residua
Such an
of the impulse are not obliterated by new aims.
impulse becomes, so to speak, an incidental impulse which
breaks through the more or less aimless operations of the
will
and becomes more
disturbance
is
insistent with each repetition.
called stereotypy
This
(Kahlbaum).
Whenever stereotypy is marked (a) by a blocking of the

will we find a continuous tension of definite muscle groups;
whenever it is marked (6) by crossing of voluntary impulses
we find a reiterated repetition of the same movement,
(a) In muscular tension the patients remain in the same
place and attitude for an almost incredible length of time
in spite of the greatest discomfort. They stand in the same
corner, kneel in a definite place,
up and head extended, so
lie
in
bed with
legs curled
rigid that they can be lifted like
Others grip a piece of bedspread with their teeth,

log.
or convulsively grasp a piece of bread or torn-off button.
The expression of the countenance is also rigid, mask-like,
a
the forehead
drawn up as
if
in surprise, the eyebrows ele-
86
The eyeballs are often
are
lips
protruded like a snout.
vated and the eyes often wide open.

turned side wise and the
(b) Stereotyped
movements have an unlimited variety. The
patients turn somersaults, rap rhythmically, walk about in

peculiar places, hop, jump up and down, roll and creep on
the ground, pick at the clothing or hair, and grit the teeth.
These movements can be repeated innumerable times, for

weeks or even months. In all these movements the patients
are absolutely reckless of themselves and their environment.
Mannerisms are a kind of stereotyped movement, consisting of ordinary
movements
patients walk with a peculiar
peculiarly modified.
gait,
drag one
foot,
The
go in
straight lines or in circles, hold their spoons at the very

end, eat in a definite rhythm, and shake hands with stiffly
Mannerisms are especially common in

speech. Grunts, lisping, peculiar words, phrases, and inflection, and numerous repetitions of the same words are
among the most frequent forms. Stereotypy is a characteristic of the catatonic forms of dementia prsecox, but also
occurs in exhaustion psychoses and in paresis, where it is
extended fingers.
only a transient symptom.

In the end stages of catatonia there
is occasionally observed a form of stereotypy which is scarcely the same

as that just described. It consists of peculiar rhythmical
movements, especially rocking the body while sitting and
standing, nodding or shaking the head, clapping of the

hands, etc. This symptom always indicates a complete
deterioration of the will.
It
is
likewise observed in the
most profound idiocy. It is a fair hypothesis that these

movements are the expression of certain primitive arrangements of our nervous system, which in the absence of the
higher processes determine the activities.
In stereotypy voluntary activity never proceeds to a goal.
87
Even when the
patients are active their activities move in a

circle.
On the other hand, there is a type of crossing of
impulses in which the incidental impulses produce only a
superfluous embellishment of the intended act. The act is
finally
accomplished, but only after
The
deviations.
and
go backward, walk
all sorts
patients skitter along,
of additions
on their knees, bend away backward, or drag one foot:

they extend their hands in wide circles, or with sudden
swoops or stiff jerks. In shaking hands they touch one's
hand only with the little finger, or with the back of the
hand. In eating they grasp the spoon by the tip, arrange
the food in
ful;
little piles,
is
peculiar way. The catatonic grimacing

garded as belonging here.
From
mouth-
drunk in little sips or after long pauses.

clothing and their garments are arranged in a
the water
The bed
or count seven between each
this
may
also be re-
embellishment of conduct there are regular

which have been termed
transitions to those disturbances
where acts are completed

from
the
in
which they are begun.
very differently
way
For instance, in grasping the spoon to eat the patients may
twirl it about in a circle, then lay it down again, or in carrying a glass of water to the mouth upset it on the table,
by
Schtiles derailment of the will,
suddenly turn it upside down, and return it to the table.

Also in their speech it is often observed that the patients
suddenly stop and begin anew with another thought,

which in turn is just as abruptly left for another, so that
will
the goal idea
is finally lost sight of.

It is in this way that
desultoriness arises (see p. 40).
In this crossing of impulses many of the acts stand in no definite relation to any
goal idea. The patient suddenly beats his companion,

perches himself like a bird on the foot of the bed, grips
his finger in the anus, stands
on
his head, or filths
on
his
88
dinner plate.
and
Occasionally, aggressive
violent attacks
originate in this way.
In this derailment of impulses one gets the impression

that the original purpose in the act is forced into the background;
for instance, the patient will exert the greatest
effort of the will
when
started in a certain direction
when
he could easily succeed by making a little detour. He will

push persistently against a locked door toward which he
has started when he could easily leave the room by an open
door close at hand.
In the description
Diminished Susceptibility of the Will.

of the blocking of the will
it
was shown how, under
cer-
tain circumstances, every impulse of the will can be rendered

The blocking of the will is
ineffective by counter impulses.
but a partial symptom of a very general disturbance
namely,
the impulsive resistance to every outer influence of the
will,
which by Kahlbaum has been designated negativism.
In
a blocking of
external impressions,
an inaccessibility to social intercourse, and an opposition to
every request; and it may even extend to the regular per-
negativism there
is
all
formance of contrary actions (the negativism of command),

and finally to the suppression of nature's demands, as in
micturition.
In this way conduct in every respect becomes just the

opposite of that which is striven for and that which would
be expected normally.
Patients do just the opposite of
that which they are requested to do
press their teeth
:
when asked
when an attempt
together
to
eyes
is
and
refuse
they
sometimes
to
answer
speak
show
made
their tongue, close the

to examine their pupils,
mutism,
questions
spontaneously.
most powerful, but almost always

every external encroachment:
will
They
although
the
offer
passive, resistance
to
not allow any one to
89
dress or undress them, will not bathe or take care of

themselves, and offer strenuous resistance to compulsory
feeding,
but when unmolested eat greedily.
The
feces
are often retained with the greatest exertion, especially if

As soon as they are
the patients are taken to the closet.
returned to bed, the evacuation immediately takes place.
They
own bed and crawling into

smear and spoil their own food,
may be even better, and steal or fight for that of
persist in leaving their
others, likewise they will
although
it
The impulsive character
their companions.
most
clearly
of its origin is
demonstrated in the occasional cases of nega-
Such patients continue lying on their

back if requested to arise, or they turn around if asked
to go forward, and remain silent if told to speak.
Negativism is not due to voluntary opposition. Patients
sometimes admit after the attack that they do not know
why they acted as they did. Negativism, stereotypy, and
loss of will probably all have the same basis.
They often
occur in the same patient, and may be easily made to pass
into one another. These various disturbances of the will
are most frequent in catatonia, and are sometimes found
in a less pronounced form in paresis, senile dementia, and
tivism to requests.
idiocy.
Catatonic negativism must not be confused with the conIn catatonia there is
scious resistance of terrified patients.
no conscious reason for resistance, and no persuasion can

overcome it. It is not influenced by pain, and the manner
of resistance is
appropriate.
always constrained and often absurdly
The
hysteria, paresis,
stubbornness
and
senile
of
imbecility,
dementia
is
in-
epilepsy,
closely allied to
negativism, but in contrast to negativism it always starts

with an idea, and is more or less influenced by persuasion,
new
ideas,
and emotional changes.
Moreover, in stubborn-
90
ness the general emotional attitude

unruly.
The
patient shows
fight,
is fretful, irritable,
and
is
and
often dominated
by confused, malevolent delusions, whereas the negativistic

patient shows great equanimity, seldom defends himself,
and almost never attacks, but merely resists.
Compulsive acts are those which do not
Compulsive Acts.
normal
antecedent
consciousness of motive and
from
arise
desire, but
which
seem
is not his
to the
own.
the morbid impulses;
upon him by a will

the
rule,
patients struggle against
often caution those about them at
patient to be forced
As a
to prevent harm to
others.
The accomplishment of the act is accompanied by
a feeling of relief, and is usually followed by clear insight
their approach,
and adopt measures
into the nature of the act, accompanied
by chagrin and
remorse.
Compulsory acts are generally accompanied by great emoand stand in close relation to compulsory
ideas and fears already described (see p. 69). These disturbances all originate on a basis of congenital morbid endowment, and are all a part of the symptoms of the contional excitement,
stitutional psychopathic states.
Impulsive Acts.
Impulsive acts are distinguished from
in
that
compulsive acts,
they do not seem to the patient to be
influenced from without, but are the direct expression of a
sudden overwhelming impulse, which gives no chance for
reflec-
tion or resistance.
They
are found in the
most varied morbid conditions.
Probably the pressure of activity in manic forms of manicdepressive insanity is of this type. Here belong also the
wanderings
and
assaults
of
the epileptic
(see p. 446),
the excesses of the dipsomaniac, as well as the morbid
impulses of hysteria, self-inflicted injury, theft, and fraud,

Their origin does not lie in definite feelings of pleasure or

dislike,
but in marked motor excitement.
91
The outbursts
of the catatonic are. thoroughly representative of impulsive

acts, although the basis lies not in a pleasurable or un-
pleasurable feeling but in a powerful pressure of movement.

The patient is controlled by the consciousness that he must
do
this or that,
without a definite reason and without fore-
thought, although he sometimes appreciates the foolishness

of his act.
Occasionally there is an idea that his limbs are
controlled
by an
invisible power, as
electrical influence.
The
patient 's
God, the
devil, or
consciousness
is
some
domi-
nated by one blind impulse without clear motive or realization of the outcome. There is no opportunity to resist the
impulse.
The execution
is
rapid and reckless, and the paThis is clearly seen
tients are correspondingly dangerous.
in the impulsive acts of the catatonic, such as the shouting,
sudden attacks, denuding, the senseless attempts to strangle

themselves, to cut out the tongue, and to gouge out the
eyes.
A disturbance of the natural impulses

Morbid Impulses.
is a symptom of all general morbid changes of volitional
In paralysis and inhibition of psychic processes all
action.
the appetites are diminished; in excitement, on the other
hand, appetites are increased, especially sexual desires. The
latter seldom lead to actual assault, but manifest themselves
in
ambiguous phrases, abusive language, and by more or
masturbation: in women, by shameless exextreme

uncleanliness, or incessant washing with
posures,
less reckless
combing and unloosing the hair; in

and flirtation, by an alternaadornment
lighter forms, by
tion between seductive, shamefaced, and sentimental manners, by hand pressing, letter writing, significant glances,
and the like. Less frequently in manic excitement there
is found an increased desire for food, although restlessness
water, saliva, or urine,
92
usually hinders the patients from taking sufficient nourishment. On the other hand, excessive greediness is not infrequently found in idiots, paretics, and especially in catatonics.
Incredible quantities of the
disgusting
things, sand,
stones,
most unpalatable and
seaweed, feces,
etc.,
are
sometimes devoured by such patients. In these last cases

there is not a simple increase of healthy impulses, but probably a simultaneous perversion of the appetite both in nature
and
The same
direction.
is
true of the well-known excessive
by pregnant women.
Much more numerous, however, are the morbid sexual impulses, which in recent years have been most thoroughly
The most pronounced of these are the coninvestigated.
sexual
trary
instincts, in which the sexual feelings and desires
are exclusively directed toward members of the patients' own
desire for eating suddenly manifested
sex.
Sadism consists
in the
attempt to increase or induce
sexual excitement by brutality. In the final stage of its

development actual sexual congress is a matter of indiffer-
In masochism, on the other hand, the endurance of

pain increases sexual excitation or may be substituted for
it.
The satisfaction of sadism appears to arise from the
ence.
power over the victim, while that of

from the most complete subjection to the
In fetichism particular articles of clothing
feeling of absolute
masochism
arises
will of another.
or parts of the
body become
either the necessary adjuncts
for satisfactory coitus, or the simple observation or contact
with the fetich
may
satisfy the sexual impulse.
common
fetiches are boots,
clothing,
and
finally velvet
The most
shoes, handkerchiefs, under-
and
furs.
Besides the perversion of normal impulses as seen in the

above, there is a group of morbid impulses which seem to
bear no relation to normal
life.
Such are kleptomania, the

irresistible
impulse to steal
all
manner
93
of worthless
and
things; pyromania, the impulse to burn. Both

these usually arise on the basis of an epileptic or hysterical
useless
endowment.
The whole series of abnormal impulses are partial symptoms of a general morbid endowment, and indicate conIt is possible that kleptomania and
genital degeneracy.
pyromania should be regarded as compulsive acts.
impulse appears as an obtrusive compulsion which
sisted as long as possible, while the
is
accompanied by a feeling of
Disturbances of Expression.
their
The
is
re-
performance of the act
relief.
The movements by which

feelings, and impulses are
ideas,
patients express
among the most important clews to morbid psychic impulses.
full delineation of the symptoms of the various disease
types occurs in the clinical portion of this work. In this

place we confine ourselves to a few characteristic indications.
Dementia prsecox
indicated
by lack of interest, notwithstanding accurate apprehension, by listlessness, strained

is
attitudes, senseless grinning or laughter, with
petuous movements.
sudden im-
In dementia prsecox the change that
movements is very striking,

particularly the loss of grace. The catatonic movements
are either stiff and wooden on account of the superfluous
tension; or careless and listless as a result of an insufficient
expenditure of energy; and again they are gross and awkward because associated groups of muscles are involved in
the movements.
The naturalness of the movements is
occurs in the character of
destroyed by the tendency to ornamentation, which gives

them the appearance of being affected, and finally there is
a lack of uniformity in the movements of expression.

Paretics may often be recognized by their awkward
friendliness
and production
of silly expansive ideas.
De-
94
pressed patients sit around collapsed and flaccid, with

troubled expression. Their movements are slow and laborious.
The apprehensive
patients are restless, bite their
In extreme retardation, they

nails, and wring their hands.
lie motionless in bed with fixed expression and whisper their
The
answers with great exertion.
manic-depressive, on
the contrary, moves rapidly about, talks, cries, sings, plays

tricks on his fellows, and busies himself with all sorts of
things.
hair to
The hysterical patients arrange their clothing and

make an impression. The paranoiac endures his
hospital confinement with dignity, carrying with
documents which prove
him the
all his
pretensions.
Alterations of speech and writing are of the greatest
diagnostic value. Delusions are usually betrayed by the
content of the communications. In manic patients there
incessant babbling, with a tendency to puns and rhymes.

This is also found in excited paretics with more or less disIn both diseases speech may
turbance of articulation.
is
be reduced to an incomprehensible gibberish, though from

different causes.
In retarded patients speech
is
low and
difficult.
Melan-
and often keep

Catatonics are often mute
choliacs express their thoughts laconically,
up a monotonous lamentation.
for weeks at a time, and then suddenly begin
fluently or sing, although more or less confusion
to speak
of speech
always present. Their stereo typy is manifested by constant repetition of the same words, phrases, or even senseless syllables, while they frequently make up entirely new
is
words.
Disturbances of writing correspond both in content and

form with those of speech. The manic-depressive patient
fills sheet after sheet of
paper with large, showy, and hastily
written characters, which are often illegible even to the

writer.
The
ment
words and
of
uncertainty.
95
shows omission, misplacesyllables, blots, untidy corrections, and

Hysterical patients use innumerable marks
paretic's writing
In melancholiacs the individual characters are

incomplete, small, and crowded. The same is true in retardation. Catatonic patients cover the paper with uninfor emphasis.
written verbigeration.
repeated
In psychoses associated with brain lesions there are apt
to be present disturbances of speech and writing such as
telligible scrawls, endlessly
aphasia, paraphasia, agraphia, paragraphia, perseveration,

and to combine letters into words and
inability to read
syllables,
indistinct enunciation, scanning or
monotonous
speech, also ataxia in writing.
Conduct arising from a Morbid Basis.
Since conduct
is
the expression of the entire psychic life, we readily understand why it is more or less seriously disturbed by morbid
changes in any part of the psychic individual, while, on the

other hand, no isolated act can be taken as an infallible
index of the exact morbid condition. Delusions of sinfulness impel patients to penance, self-mutilation, or suicide.
Delusions of persecution lead to mysterious precautions, to
misanthropic isolation, to restless wandering, or even to
outbursts of rage and murderous attacks against supposed

enemies. Hypochrondriacal delusions may lead to revolting smearing, self-mutilation, or injurious and absurd curative attempts, often with the evident purpose of attracting
attention and sympathy.
Mental excitement very soon leads to conflicts with the

environment, to breaches of the public order, and quite often
to resistance to civic authority.
Patients behave in a reck-
and striking manner. They are ungovernable, irritable,

and violent under contradiction and restraint. At first
they act as if intoxicated, and later become still more restless
96
and even dangerous. There is usually also a tendency

to sexual excesses, in which they indulge without regard to
decency or morality. Such excited states are regularly ac-
less
companied by all sorts of mad pranks, destruction of property,

adventurous journeys, brawls, and public scandals. When
associated with expansive ideas, the patients purchase large
amounts of useless stuff, prepare

and spend large sums of money.
in their neighborhood belongs to
for mythical undertakings,
The idea that everything

them induces the patients
to innocently appropriate whatever they

embezzlement, or to fraud.
happen
on,
to
Paranoiacs systematically prepare their claims, address
and publish pamphlets. In

notice
compel
they appear on the street
in unusual costumes, attack prominent persons, and create
letters to
prominent
officials,
their attempts to
public scandals. Love-letters, proposals, etc., are directed

at the supposed secret lover. The religious paranoiac founds
a church and seeks a martyr's crown.
METHODS OF EXAMINATION
IN mental disease
it is
utmost importance that the

routine method of examination of
of the
student employ a definite

the patient. Any method to be satisfactory must include
the (a) anamnesis of the family, and (6) personal history
previous to the disease, (c) the anamnesis of the disease,
(d) and finally the status praesens.
(a) The importance of heredity as an etiological factor
necessitates a careful consideration of the family history,
not only as regards the presence of mental and neurological
diseases,
tion.
but also evidences of defective physical constitunever be elicited by simply asking the
This can
general question if there is a history of insanity or nervous

diseases in the family, but it requires a detailed inquiry
into the habits, traits, and physical illnesses of all the members of the direct branches of the family, laying particular
upon mental peculiarities, alcoholic and other addic-
stress
tions,
and
The
criminal tendencies.
personal history should begin with an inquiry

into the conditions attending gestation and birth, such as,
(6)
exhausting diseases, deprivation, severe emotional shocks,

mental anguish, and birth trauma. In infancy there is the
and their sequelae, convulsions, head injury, paralyses and the tardy appearance
of walking and talking, and in childhood, the progress in
school and conditions accompanying puberty and menstruapresence
of
infectious
diseases
tion, also the existence of
masturbation, sexual impulses,

emotional
peculiar
manifestations, timidity, morbid temH
97
98
peraments, religious experiences, etc. If married, the conditions attending child-bearing should be known, as well as
severe illnesses, such as, typhoid fever, injuries, mental
and deprivation; and
shocks,
if
employed, the character of
the work, the materials handled, the sanitation and undue
and mental strain, excessive indulgence in eating,

Perdrinking, and amusement, and also drug habituation.
physical
exaggerated egotism, one-sided intellectual development, with attainments in one field and
sonal
idiosyncrasies,
lack of development in another, should be included in your

list
of inquiries.
In
eliciting
such facts
it
should be borne in
mind that
It
general questions are wholly inadequate.
requires close and detailed questioning, and even then important facts are very apt to be overlooked.
In determining the cause of the disease one should guard

against mistaking for causes the actual early symptoms of
disease; such as the excesses of the paretic, the self-con-
demnation of the melancholiac, and the masturbation
of the
hebephrenic.
In
the anamnesis of the disease particular attention should be paid to the character of the onset and the
(c)
eliciting
In securing this information it is usually

most satisfactory to follow out the outline prescribed for making a mental status; i.e. elicit information concerning the
symptoms
to date.
presence of hallucinations or illusions at various periods, of

disorder of orientation, attention, memory, train of thought,
judgment, and in the emotional and volitional fields.

It is often difficult to determine the actual date of onset
of the disease because the initial
change in disposition
is
sometimes so insidious that the true significance of certain

peculiarities is not appreciated until emphasized later by the
occurrence of the more striking symptoms. In case there
have been one or more previous attacks of mental disease
there should be the
character of the
their duration,
same
careful inquiry not only into the
symptoms presented at these periods and
but also particularly as to whether the patient
fully recovered or suffered residual defects in
the mental
99
some
field of
life.
(d) Status prcesens.
This êxamination should include ob-
servations of both the physical and mental conditions of

the patient. In view of the fact that many persons are
particularly sensitive about undergoing a mental examination
it is desirable to begin with the physical examination.
Dur-
ing it there is always opportunity to frame questions in such

a way that the answers will give valuable information as
to the mental state; as, for instance, the memory can be
determined by questions as to the date of appearance of

certain physical signs, or the orientation may be ascertained
by questions as to those who are caring

their food
for them,
by
whom
prepared, etc. Indeed, the great variety of

physical symptoms to be inquired into offers sufficient chance
to cover all fields of the mental status; even hallucinations
and
is
illusions of hearing
and
sight
may
be disclosed by the
examination of the senses of hearing and sight.

The general survey of the body should include the state
of nutrition, the present
body weight compared with
earlier
weights, the presence of anaemia or cachexia, signs of premature senility, or delayed pubescence, also evidences of socalled physical stigmata, as harelip, malformation of the
palate, of the ears, or sexual organs, albinism, congenital
strabismus, malposition of the teeth and eyes, etc. Trauma,

scars, and residuals of previous diseases should not be over-
and
particularly those of syphilis. The physical

examination should be careful enough to eliminate such
looked,
chronic diseases
as
chronic nephritis, uraemia, diabetes,

pernicious anaemia, Graves' disease, tuberculosis, syphilis,
100
lead poisoning, and chronic gastritis. The condition of

sleep and of the gastro-intestinal tract needs special attention because of the frequency with which disturbances exist
in these fields.
In the examination of the nervous system, the measurements of the cranium will give some indication as to the
development of the cortex, but it is of more importance to

observe the disproportion between the cranium and the rest
of the body.
The circumference
of the skull taken along
the line just above the external occipital protuberance and

the glabella should measure in an adult between 48 and 56
centimeters, while the distance between the extreme lateral
points as taken by craniometer should be between 14 and 15
centimeters. The examination of the eye grounds should

not be omitted, as it often reveals vascular sclerosis, which
might otherwise escape notice. Likewise, a careful ex-
amination of the ears sometimes discloses a
sufficient cause
for peripheral hallucinations.
Then the muscular system should be examined. First

determine the condition of muscular tonicity by employing
passive movements and examining the tendon reflexes.
Both of these may be difficult on account of lack of cooperation and inability to secure complete relaxation of the limbs;
hence
important to have the patients in a comfortable

and restful attitude, such as in a recumbent position, with
it is
by engaging them in conversation,

giving them figures to add or something to read aloud.
In eliciting the knee jerks, if the patient is lying on his back,
place left hand beneath the knee and gently lift it, allowing
the foot to rest on the bed. If you find the leg relaxed, strike
their attention distracted
the tendon at any time.

relax until
will
Frequently the patient will not

have
raised
the knee high enough so that it
you
support
itself in
that position.
If the patient is sitting,
101
he should recline backward in an easy posture, with both feet

squarely on the floor and brought as far forward as possible
without causing the toes to leave the floor.
The ankle clonus is best elicited now by slipping the right

hand under the toes and sole of the foot and quickly jerking
the foot
upward
for a
few inches, so that the weight of the
elevated leg and thigh rests on your hand.

The Achilles
is
determined
the
to
stand
jerk
by asking
patient
leaning
forward and supporting his weight by placing his hands on

the top of a table or back of a chair. The ankle is then
and allowed to rest on your knee, when the

struck. The wrist and jaw reflexes should also be
lifted in the rear
tendon
is
determined.
The muscles should be examined further by palpation and

by the exercise of active movements which will determine the
presence of paralysis (flaccid, spastic, or accompanied by
Such
contractures), as well as disturbances of coordination.
movements are the voluntary
raising of the legs while the
patient
recumbent, attempts to touch the knee, to touch
the end of the nose with the forefinger with or without
closed eyes, standing erect with eyes closed and feet close
is
together, closing the eyes, opening the mouth, and protruding
the tongue upon command, and then reversing the order.

These tests should also include voluntary writing, and speech,
as well as the enunciation of different words, such as "electricity," "Massachusetts artillery brigade," "around the rugged
rock the ragged rascal ran." The movements employed
above will also demonstrate tremors (fine, coarse, fibrillary,
and retractile of the tongue), which should be noted.

The mechanical irritability of the muscles and the nerves
is then determined by percussion of the muscles, and the
mechanical stimulation of the peripheral nerves. The nature
of
spasms should also be investigated
(epileptic, hysterical,
102
and athetoid).
Finally, the irritability of the muscles

nerves to electricity, wherever there are indications for
choreic,
and
should be determined, since disturbances in it as

well as in all of these other fields may have distinct bearing
its use,
upon the general brain
condition.
Following this the sensibility should
be tested, including
the sensations of pain, touch, and temperature, for areas of

hypersesthesia, analgesia,
and
paraesthesia.
For
this pur-
pose the simplest implements are the best; namely, a camel' shair brush, a needle, and small bottles of hot and cold water.
It
may also be necessary to examine the stereognostic sense.

Vasomotor, secretory, and trophic disorders should be
recognized and recorded, particularly cyanosis of the extremities,
dermography, glossy
skin,
canities,
chogryphosis, naevi, herpes, scleroderma,

the various trophic disorders of the bones
ony-
alopecia,
and hyperidrosis;
and joints, includ-
ing spontaneous fractures and hsemotama auris.

In the examination of the pulse there is nothing to be
found peculiarly characteristic of any special form of mental
The blood
and depressive
states is usually elevated, and depressed in manic states,
corresponding with the vasomotor symptoms ordinarily
accompanying these states. The fall in blood pressure
observed in the end stages of paresis is in accord with the
progressive terminal cardiac weakness. The examination
disease.
pressure
in
fearful
been thus far unproductive of characteristic

In
disorders.
any given psychosis the blood states may
vary considerably in the different stages. In the psychoses
of the blood has
studied by us
1
dementia prsecox, manic-depressive insanity,
"Blood Changes
in
Dementia Paralytica," American Journal
of
Med.
Soc., Vol. 126, p. 1074.
"A
Contribution to the Study of Blood in Manic Depressive Insanity,"
American Journal
of Insanity,
LIX, No.
4,
1903.
103
and dementia paralytica
the only apparently characterblood states were those found in dementia paralytica,
istic
where there was a progressive anaemia and a progressive

increase of polymorphonuclear leucocytes accompanying
the advancing course of the disease and the presence of a
The chemical
leucocytosis accompanying paralytic attacks.
investigations of the urine, gastric contents,
and
of
body
metabolism, while still fruitful fields for study, do not warrant

routine examinations except in the matter of urine and gastric
contents to obtain indications for treatment.
careful physical examination should include in doubtful

cases the examination of the cerebrospinal fluid for the pur-
pose of differentiating between functional or organic disAs much depends upon the technique, the method
eases.
stated.
is briefly
needle
is
vertebrae,
This
is
speed
is
With the
strictest aseptic precautions the
inserted between the fourth and fifth lumbar

and three or four centimeters of fluid withdrawn.
if the
immediately centrifugalized 10 minutes
if only 2500 revo3000 revolutions, or 30 minutes
The supernatant fluid is poured

out of the glass and then a pipette is carefully introduced into
the bottom of the tube and the sediment all withdrawn.
lutions can be obtained.
This
is
thoroughly mixed by blowing
sucking
it
up
again,
when
it
out into the tube and
three drops of equal size are
dropped on three
slides, which are allowed to dry in the air.

The slides are fixed by a half-hour immersion in equal parts
of absolute alcohol and ether, stained with a few drops of
Unna's polychrome methylene blue, washed in water,

then in alcohol, cleared in xylol, and mounted in balsam.
With a magnification of 300 to 400 times the presence of three

or four lymphocytes in a single field may be regarded as
normal. At least three lumbar punctures are necessary
for
final decision.
The
bacteriological examination of the
104
cerebrospinal fluid as well as of the blood has thus far yielded

such varying results in the hands of different observers that
a routine examination cannot be recommended for diagnostic purposes.
The most
difficult
mental status.
part of the examination
securing the
depends upon the
In this matter much
is
acuteness of the observer, as the patient often enough cannot
be depended upon for cooperation. Unfortunately, we have

no scientific standards for determining the mental symptoms,
but must depend upon the simplest psychological
tests;
namely, the asking of questions.

For convenience and thoroughness of examination
most important to always have before one an outline
it is
of the
method of examination. If for purposes of record or otherwise, and particularly in medico-legal cases, it is necessary
to write down the observations, it is always best to write in
full the question and the answer verbatim as given by the
patient.
Upon subsequent examinations the same questions
should be asked, and the answers compared. The general
arrangement
of
this
should
outline
follow
closely
the
presentation of the general symptomatology; i.e. disturbances of perception, clouding of consciousness, disturbances
of apprehension, of attention, of
memory,
of orientation, of the
train of thought, of judgment, of the emotions,
and
of the voli-
tions.
1.
Perception (hallucinations and illuHallucinations can oftentimes be most readily
Disturbances of
sions).
elicited
by asking the patient
sees pictures or visions, or,

if
if
directly
if
he hears voices or
this question is not understood,
he hears noises or voices when no one
is
about him.
Fre-
quently the patient does not consider the hallucinations as a

peculiar sensory experience
negatively.
and
will
answer your questions
Then he should be questioned
closely as to
how he
sleeps nights,
Again, he
may
105
and whether or not he
is
disturbed.
be questioned as to whether or not intimate
shopmates, employers, or business associates,

whom you know to be absent, converse with him. Such
questions often elicit the desired evidence of hallucinations.
associates,
Sometimes sense deceptions are
elicited only
for the basis of certain delusions held
when one
seeks
by the patient, when,
will admit that he believes he is persecuted

remarks that he hears. Patients observed
assuming listening attitudes and addressing remarks to
unseen persons, or gesticulating earnestly in a definite
for instance,
because
he
of
direction, or persistently spitting out or casting aside
good
as
be
regarded
suffering
may
from sense deceptions, although these are denied by them
when questioned directly. In the matter of religious
food without adequate reason,
hallucinations, such as the voice of God, one should be

"
"
voice of conscience
particularly careful not to mistake the
or the
"
distinction
which some
sometimes what in
"
as genuine hallucinations, a
patients are loath to admit. Again,
voice of the heart
many appear
to be true hallucinations
are not such, but are really genuine perceptions. In this

matter one cannot exercise too great care. What has been
indicated in reference to hallucinations
and hearing
and
illusions of sight
refers equally well to the hallucinations
and
illusions of the other senses.
Clouding of Consciousness and Disturbances of ApThe determination of unconsciousness, of

prehension.
2.
befogged states, and of diminished sensibility depends mostly

in clinical practice upon the patient's reaction to definite
one uses in any neurological examination ;

namely, the test of pain and touch sense by the use of the
stimuli, such as
needle, of hearing by the use of speech, of sight by writing

tests or the perception of colors.
Further, the compre-
106
hension of simple or confused pictures (medleys) placed

before the patients gives an insight into these defects.
such as Hipp's chronoscope and the apparatus of Ranschburg, have been devised for the accurate
determination of the process of perception, which are not
Many elaborate
tests,
wholly suitable for general application or for bedside use.

Attention (blunting, blocking,
3. The Disturbances of
and
retardation, passivity,
distractibility) can usually be
determined in a satisfactory manner by the use of the progressive adding and subtracting test, such as, subtracting
7 successively from 100 down to 0. The variations in the
rapidity and the occasional blocking afford good demonstrations of the stability of the attention. The introduction
of distracting influences during the test, such as dropping a
cent upon the floor, will bring out distractibility of attention.

In the application of such a test one must always take into
account the social grade of the individual as well as the degree
of his education.
4.
Memory
accuracy, and
(defects
in
the
impressibility,
retentiveness,
The
retentiveness
fabrications of memory).
usually determined by a series of questions

directed toward the retention of certain school knowledge,
of
memory
is
such as the multiplication table ; or the uninterrupted adding

or subtracting of 3, 7, or 12, the time required being measured
by a stop-watch.
The
retentiveness in patients sensitive
to being subjected to such tests can be estimated only
by
asking questions concerning the past personal experiences or

facts in history.
The
memory can be most
readily determined by asking the patient to repeat numbers of more

than one figure which are dictated to him ; also unfamiliar
impressibility of
combinations of syllables. This may be done both orally

and by writing. Again, he may be asked to recognize in a
107
group of pictures a certain picture which has previously

been shown to him. Questions directed to ascertaining
recent occurrences in their daily lives, such as what he had
for dinner yesterday,
him,
may
what the nurse or doctor
is doing for
In the determination of both the
be asked.
and
retentiveness
must never demand
impressibility one
from an uneducated person more than he ever acquired.

The accuracy of memory and the fabrications will already
have been elicited by the questions asked in reference to
remote and recent personal experiences.
5.
Orientation
orientation
and
(apathetic,
perplexity).
amnesic, and delusional disThe orientation as to time,
and persons
is determined by such questions as:

the date of the month, the day of the week, and
" "
the season and year?
Where are you now? " " What
place,
"
is
What
the
is
name of the place,

"
of the city?
duty here,
"
Who
and what
is
of the building
and its character, and
are these persons about you, their

"
In case the
your mission here?
patient is not disposed to or is unable to respond, his orientation as well as his power of apprehension can be determined
carefully his conduct in his environment;
for instance, noting the names with which he addresses his
by watching
associates, his religious observances, his ability to find his

way about in familiar environment, etc.
6.
of
Train of
thought,
Thought (paralysis
of
thought, retardation
compulsive ideas, simple persistent ideas, per-
severation, circumstantiality, flight of ideas, desultoriness).

If the patient is at all communicative and has answered the
foregoing questions, you already have

to judge of the wealth of his store of
its
impoverishment,
if
had some opportunity

ideas, or the degree of
some extent of all of the

thought, and particularly
present; also to
other disturbances of the train of
the retardation of thought.
If the patient is productive
108
and volunteers much speech, there
is usually little difficulty

of
in determining the presence
simple persistent ideas, cirof
In case
ideas, and desultoriness.
cumstantiality, flight
not productive, the disturbances in the content

of thought can be elicited by requesting him to recite
connectedly the incidents of some recent personal experience;
the patient
is
such as the detailed account of the nurse's method of caring

for him or the account of the journey to the hospital.
It
may be necessary in
order to keep the patient talking to con-
"
"
Is that
Yes, yes," or,
tinually urge him by interjecting
"
In this way circumstantiality, flight of ideas, and
so?
desultoriness is usually detected. Another method is to
peruse the voluntary writings of the patient, particularly
home
letters.
There are
many more
associations of ideas.
accurate tests for determining the

these, the one most easily carried
Of
out at the bedside is to give the patient any sort of a word,

such as "horse," and then ask him to speak aloud the ideas
arising in his mind, which you may write down, or you
ask
the patient himself to write down all ideas occurring
may
to him in a definite period of time after being given the initial
first
way one can obtain some conception of the

the inner and external associations, of
between
relationship
word.
In this
the prominence and frequency of fixed associations, senseless

and sound associations, of Uniformity and the desultoriness
of the train of thought, as well as the wealth of the store of
ideas, the tendencies to
sudden
cessations, or the tenacious
holding of a single idea.
Usually by the time one

(delusions).
has reached this stage of the examination real delusions
7.
Judgment
have been actually expressed or some hints have been accidentally dropped which will serve as a basis for further
questioning.
In determining delusions, direct questions
are less pernicious than in eliciting
some
109
of the other
mental
symptoms. One may ask the patient if he is troubled in

any way, if the affairs at home are moving smoothly, if
his business is successful, and if he is at all apprehensive
of his welfare, etc.
Should your patient show considerable
and
refuse to speak of personal matters, as often

happens immediately after his liberty is restrained or he is
placed in a new environment, one must be tactful in approach-
reserve
ing the matter of delusions. Sometimes the simple direct

question as to why he has been deprived of his liberty or
submitted to the care of the physician may be sufficient.

Again, it may be necessary to introduce a subject of much
interest to him, such as his employment, literature, or travel-
may be
asked to express his judgment as to cost

of manufacture of the material with which he works, the
ling,
or he
contentions of trade unions, the utility of trusts, or his

opinion of the countries in which he may have travelled. A
free discussion of a
matter of general
interest,
but at the same
time bearing upon the individual's livelihood, usually uncovers some of his delusions, if any be present. In the case
of women, domestic difficulties, church or social relations,
and especially neighborhood differences, are usually fruitful
The various somatic
sources for discussion and inquiry.
delusions are most often brought out by questions as to the
health of all the various organs of the body. The evidence
of systematization of delusions can often be best determined
"
What is the object of all this? " or,
by asking directly,
"
"
these various ideas bear any relation to each other ?
Defective judgment in other matters than delusions will
Do
usually be established by such general discussions as those

"
What do you think
advised above or by such questions as,
"
"
of the restriction of your liberty?
How much does it
"
cost you to live ?
"Are you receiving sufficient wages, and
110
" "
within your income?
Figure up your cost
"
of living."
Who aids in the support of your family, and
do they do as much as they should? " etc.
do you
live
Emotional Field (emotional deterioration, increase

emotional
irritability, sad disposition, irritable disposition,
of
8.
seclusiveness,
sunny
disposition, fanaticism, morbid frivolity,
fear, phobias, dejection, sadness, feelings of pleasure, feeling
of well-being, disturbances of hunger, nausea, pain,
the sexual feelings.)
In this
field
and
of
one has to depend rather
more upon observation than upon interrogation
of
the
patient, as there is large opportunity for simulation and

Most patients if asked if they loved their parfalsehood.
"
Yes " even though they might be totally
ents would say
and exhibiting profound emotional

deterioration.
One rather has to rely upon the observations of others as to relations which the patient maintains
with his family, in his work, and in his social environment,
which would exhibit increased and diminished emotional
Likewise one
irritability and persistent sadness or elation.
barren of
all
affection
cannot depend upon the patient for accurate observations

as to whether or not he is of a sad, sunny, seclusive, or irritable disposition, or given to fanaticism or morbid frivolity.
The
persistent feelings of fear, of sadness, and of well-being

usually become apparent to one during a prolonged examina-
tion
and do not need
special inquiry.
Yet
in this matter
one sometimes must ask the patient directly how he feels,

or whether or not he is fearful or dejected. The disturbances
of the general feelings of pain, of hunger, nausea,
and
of
more readily determined by observation

by questioning.
In questioning those most intimately associated with the
the sexual
life
are
of the conduct than
patient one may ask such questions as these whether or not

there has been a change of disposition; previous to illness
:
was the individual of a
sition; was he fond of
sociable, cheery, or
melancholy dispo-
was he silent, timid, couraor proud and egotistical; is he
solitude,
geous, irascible, suspicious,

of his family or apathetic,
now fond
and business
111
is
he
fulfilling his
family
he negligent, disrespectful,
or insensible to the feelings and interests of others; is he
fulfilling his religious obligations, or does his general conduct
obligations, or
show unnatural
is
fear, sadness, or exaltation.
We have at best no very accurate means of measuring the

emotional side of the
of the patient.
Feelings of displeasure, of pain, fear, and anger can be created experimentally in various ways and by hypnosis, and the latter
method has been employed by Lehmann to determine the
life
influence of emotional states
upon respiration, pulse rate,

and blood pressure. Furthermore, the writing scale and the
ergograph, which are used to measure the finer expressions
of the will, are serviceable in measuring the outward expressions of emotional excitement.
9.
Volitional
Field
(paralysis of
the
will,
pressure of
psychomotor retardation, stupor, blocking 0} the

muscular tension, hypersuggestibility of the will, catalepsy,
activity,
will,
cerea flexibilitas, exhopraxia, distractibility of the will, interHere also

ference, stereotypy, mannerisms, negativism).
one must depend to a large degree upon observation of the

conduct, both spontaneous and in obedience to command or
Thus
paralysis of the will can be determined

by watching the patient's voluntary movements, also the
reaction in response to the call to dinner or when requested
suggestion.
some simple duty. Pressure of activity, retardastupor, and blocking of the will, as well as muscular
to attend
tion,
tension, are usually evinced before one has reached this stage
of the examination.
The methods of physical examination
are sure to bring out these defects as well as cerea flexibilitas
112
and catalepsy. If not, one has simply to grasp the arm and
place it in an awkward and uncomfortable position or to
command
the
patient to perform certain movements, as

walking, shaking hands, or writing. If negativism is presDistracent, it also will be elicited by these methods.
tibility of
the will, interference, stereotypy, and mannerisms
by similar commands.
The observation of the conduct by nurses and others
should be inquired into, as in this way the varying periods
of mutism, negativism, muscular tension, and tendency to
eat the food of others and to get into others' beds, to stand
in awkward and statuesque positions, can be elicited, which
are elicited
may
not be present at the time of your examination.

finer analysis of disturbances of volition, partic-
In the
ularly psychomotor excitement, retardation,
and
tension,
Kraepelin suggests the writing scale, by which one can determine the path of the writing, the rapidity, and the pressAlso the ergograph, invented by Mosso, can be employed to measure the strength of the movement, the effect
ure.
of retardation, fatigue,
and muscular
tension, as well as
the rapidity with which the contraction and relaxation of the

muscles follow under the influence of the impulses of the
Both of these instruments, however, have their
will.
drawbacks which render their routine application unsatisfactory.
The more
severe disturbances in the release of the
volitional impulses can be measured by the use of the watch,

such as in counting as rapidly as possible from 1 to 30,
rapidly repeating the alphabet, or in simply raising the arm.
CLASSIFICATION OF MENTAL DISEASES

CONSIDERATION OF THE FACTORS ENTERING INTO
A PROVISIONAL CLASSIFICATION
*
THE principle requisite in the knowledge of mental
diseases
an accurate
definition of the separate disease processes.

In the solution of this problem one must have, on the one
is
hand, knowledge of the physical changes in the cerebral

cortex, and on the other of the mental symptoms associated
with them.
Until this
is
known we cannot hope
to under-
stand the relationship between mental symptoms of disease

and the morbid physical processes underlying them, or in-
deed the causes of the entire disease process. There are

still other difficulties to be encountered in obtaining that
fundamental knowledge necessary for a scientific classification of mental diseases.

In the first place, it is almost
to
a
distinction between
establish
fundamental
impossible
the normal and the morbid mental state, as was frequently
indicated in our discussion of the general symptomatology.
It is equally difficult sometimes to distinguish between the
transition states existing between different forms of recognized types of mental disease. Again, the symptoms of the
disease are apt to be greatly influenced and exaggerated by
the morbid hereditary basis which underlies so many forms
of
mental disease.
Finally, as the functions of different
parts of the brain differ, hence the character, intensity, and

location of the morbid process influence greatly the gradations in the
form of the mental disease.

115
116
Clearly, then, there is at present
which to construct a
theless, there is
final
no sure foundation upon
standard classification.
Never-
always a demand for some grouping of our
knowledge as a basis for practical work, particularly in

teaching. Judging from experience in internal medicine,
the safest foundation for a classification of this kind
is
that
offered by pathological anatomy.

Unfortunately, however,
mental diseases thus far present but very few lesions that
have positively distinctive characteristics, and furthermore
there
is
the extreme difficulty of correlating physical and
mental morbid processes.

Likewise it has been impossible thus far to establish a
classification upon an etiological basis.
Although there are
some agents that produce very definite symptoms, such

as alcoholic intoxication, certain acute infectious diseases,
head
injury,
and
particularly the
more profound types
of
individual cases of in-
hereditary degeneracy, yet very many

sanity are wholly without any distinctive etiological factors.
And furthermore, one often has to admit that any single
may make
itself known by a great variety

the
of mental disease often
causes
Again,
pathogenic factor
of
symptoms.
work in conjunction with each
difficult to ascertain
other, rendering it extremely

the relationship between the causes and
the symptoms.
The most popular method

has been the so-called
of classifying
clinical
mental diseases
classification.
The grave
apt to be an
overvaluation of some symptoms resulting in the accumulation in one group of all cases having in common some one
defect here arises from the fact that there
is
symptom. In this way all sad and anxious emocame to be regarded as melancholia, all excited
states as mania, and delusional states accompanied by hallucinations as paranoia. The difficulty becomes apparent
striking
tional states
117
when a
single case thus classified presents during its course

the characteristics of several groups. It is, therefore, essential,
as
was pointed out by Kahlbaum,
to distinguish be-
tween transitory mental states and the disease form
The
itself.
conception of the disease demands knowledge

not only of the present state, but also of the entire course
of the disease.
scientific
Judging from our experience in internal medicine

fair
assumption that similar disease processes
identical
symptom
will
pictures, identical pathological
it is
produce
anatomy,
identical etiology.
If, therefore, we possessed a
of
comprehensive knowledge
any one of these three fields,
and an
we
pathological anatomy, symptomatology, or etiology,
would at once have a uniform and standard classification
A similar comprehensive knowledge of
of mental diseases.
either of the other two fields would give not only just as
uniform and standard classifications, but all of these classifications would exactly coincide.
Cases of mental disease
in
the
same causes must also present the same
originating
symptoms, and the same pathological findings. In accordance with this principle, it follows that a clinical grouping of psychoses must be founded equally upon all three
which should be added the experience

derived from the observation of the course, outcome, and
of these factors, to
treatment of the disease.
In the classification presented here there are treated

of all those forms of insanity that are
produced by
first
external
namely, those psychoses that arise in connection

with infectious diseases, those that follow upon severe excauses;
haustion, and finally those produced

Next are considered the psychoses
by intoxicating agencies.
presumed to bear some
faulty metabolism and auto-
relation to the products of

intoxication.
Our knowledge of these
is
definite only in
118
reference to thyrogenous insanity; but there are certain

points of similarity which would indicate that dementia prse-
cox and dementia paralytica should also be classed here.

The forms of insanity arising from diseases of the brain,
the organic dementias, comprise the next group. Here external causes also play some role, as, for instance, the
syphilitic lesions,
come the
head
injury,
insanities associated
and cerebral embolism.
Next
with the involutional period
melancholia of involution, senile dementia, and the presenile

state with delusions of prejudice.
The next group comprises manic-depressive insanity in

which a morbid constitutional basis occupies a prominent
The same condition obtains to a still more marked
position.
degree in that gradual morbid transformation of the entire
psychical personality designated paranoia, which is described
next.
In epileptic insanity, which comes next, besides the
prominent morbid constitutional basis, there often exist

other morbid conditions as head injury, arteriosclerosis, and
infectious diseases.
The
epileptic attacks
sometimes date
from some particular revolution in the physical organization.

These facts give to epilepsy an intermediate position between auto-intoxication, organic brain disease, and heredi-
We do not, however, believe that

tary mental diseases.
the disease group recognized to-day as epilepsy presents a
Further knowledge probably will disclose in
In hysteria, while the
several different disease processes.
clinical unity.
it
faulty constitutional basis is prevalent, the various forms of

mental disorder seem to be released wholly through the
action of the emotions.

Closely associated with hysteria are the insanities of degeneracy. The morbid constitutional basis encountered here
varies greatly
and
it is
often impossible to differentiate the

several different forms of psychosis.
two
large groups
119
Yet one may formulate
namely, the constitutional psychopathic
and the psychopathic personalities. The former comthose

morbid constitutional states which are recognized
prise
by being more circumscribed, as developing gradually at first,
states
or as appearing only at times; the latter include the characteristic morbid developmental forms of the entire psychic
personality, which are justly regarded as an expression of
degeneracy. In some instances this division is inadequate.

Finally there are described those forms which indicate a
mental development
an incomplete developSometimes the basis for

this lies in a faulty development of the body, but more often
there exist in the undeveloped brain disease processes, which
restriction of
ment
of the psychical personality.
produce a partial destruction of the tissue, thereby rendering mental development impossible. Strictly speaking, these
latter cases should be regarded as organic brain diseases.
We
are not yet in a position to distinguish accurately

between restricted development and diseases of the brain,
and furthermore, the mark of congenital weakness predominates to such a marked degree in the clinical pictures
that any distinction between both of these groups which
are so intimately related from an etiological standpoint
commends
itself.
Indeed, we might go even a step
and consider these forms of defective development
as states of mental weakness which were produced by
hardly
farther
profound mental disease in the earliest stages of development. Also in these cases the development of psychical
personality
was destroyed
at the outset.
In concluding the subject
many
it
should be emphasized that
of the disease pictures differentiated in the following
pages are but attempts to present a part of our observations in a form suitable for teaching purposes.
It must be
120
admitted that even to-day it is impossible, in spite of honest

efforts, to create a "system" of psychiatry that will include
all cases.
Attempts of this sort that have been made only
bring confusion. While this assertion may prove somewhat
disquieting to the student, to the investigator it means a
frank acknowledgment of real conditions and an honest
effort
to establish accurate
from our
clinical experience.
and fundamental knowledge
I.
THE mental
INFECTION PSYCHOSES
disturbances here described are supposed
from toxins of infectious diseases.
to develop primarily
They
are fever delirium, infection deliria y
and
post-febrile
psychoses.
Fever delirium follows rather closely the clinical course

and in a measure depends upon it. The
of the fever,
infection delirium corresponds to the initial deliria of other

authors, appearing at, or near, the onset of infectious dis-
The remaining group includes

eases, independently of fever.
the various forms of mental disturbance which follow the
infectious disease, developing during or following the fever,
and which are apt to lead
permanent mental enfeeblement.

Other writers describe these under the various diseases
which they accompany; as, typhoid delirium, pneumonic
delirium, influenza insanity, and insanities following exanthemata. The mental symptoms arising from the toxins
of the different infectious diseases cannot as yet be suffito
ciently differentiated to permit of their being considered

as characteristic of the corresponding disease. The only
distinguishing features are the physical symptoms characterthe different diseases. It is still a question whether
istic of
the changes in the cortical neurones are due directly to the

toxins produced by the micro-organism, or to an autotoxin
developing within the body as a result of the infectious

disease.
A.
The
FEVER DELIRIUM
clinical picture of fever delirium presents four differ-
ent grades
corresponding to the intensity of the toxic

121
122
action
upon the
cortical neurones, varying
from moderate
and finally to complete destruction.

The form of febrile disease has very little in-
irritation to paralysis
Etiology.
fluence on the type of delirium, which apparently is modified
only by the rapidity of the development of the fever, its
intensity,
and duration.
There seems to be
little
ground
for
the claim that the mental disturbance occurring during

typhoid is more or less characteristic. Besides the toxin
produced in the febrile disease, the rise in temperature,

acceleration of metabolism, and disturbance of circulation
should be regarded as causative factors. In addition there
should be included alcohol, which plays such an important
pneumonia, giving rise to symptoms characteristic
of delirium tremens, such as illusions and hallucinations of
role in
objects of great sensory vividness, the occupation delirium, tremor, and a mixed emotional state showing
both elation and anxiety. Furthermore, the individual's
many moving
power
of resistance
is
of importance.
It is well
known
that children, women, and nervous men show a tendency

to develop delirium with any severe form of fever.
The
pathological
anatomy exhibits mostly a disappearwhich can
ance of the cortical cells very similar to that
be produced experimentally by the application of superheated air to test animals as well as many other deleterious
agents.
Symptomatology.
ium
In the lightest grade of fever
delir-
is irritability, some restlessness, general hyperinsomnia

with anxious dreams, a feeling of numbsesthesia,
ness in the head, and a desire to be left alone.
there
In the next grade there

sciousness;
illusions
is
a marked clouding of con-
and hallucinations
largely
dominate
The
ideation, producing a dreamy confusion of thought.
designs on the carpet and ceiling appear as moving forms
INFECTION PSYCHOSES
123
or grinning faces, the bedpost assumes the form of an

Frightful outcries or beautiful music are heard,
angel.
patients have airy floating sensations, and are led about
These dreamy experiences are interrupted momentarily by a return to

The emotional attitude becomes
normal consciousness.
either much exalted or depressed, and motor activity inthrough gorgeously decorated rooms.
creases greatly.
In the third grade the disturbance of
consciousness
becomes very pronounced. The patients prattle constantly,

the content of thought showing even greater dreamy confusion.
There are many varied emotional outbreaks and
frequent wild impulsive movements, which soon become
irregular and uncertain, indicating the onset of paralysis.
The
intense restlessness
interrupted by short periods of
is
sleep.
In the fourth grade the movements become absolutely

At this time carphologia appears with subpurposeless.
sultus tendinum. The utterances become indistinct, and
consist in
From
mumbling over incoherent words and
this the patient
may
enter into a state of
open eyes, he is oblivious to

and
unable
to indicate his desires.
roundings
when, in spite of
sentences.
coma
vigil,
all his sur-
The urine
and fseces are passed involuntarily.

The intensity of the motor activity varies in different
individuals, sometimes reaching an extreme degree and at
other being confined to spasmodic twitching or choreiform movements of the extremities, or merely of the
face
and tongue, the
latter
producing peculiar enuncia-
tion.
Course.
The duration
of the cases does not
of the psychosis in three-fourths
extend beyond one week, and usually
the delirium subsides with the temperature.
Some
of the
124
delusional ideas held during the disease

for a long time.
The
prognosis
of the
is
may be
retained
naturally poor because of the severity

If the delirium advances to the
disease.
initial
third or fourth grade, at least one-third of the cases die.

Where there is hyperpyrexia the prognosis is extremely
A few cases emerge from the fever delirium

an exhaustion psychosis, or may end in dementia.
doubtful.
into
may be the starting-point of other

as
manic-depressive insanity, dementia prsecox,
psychoses,
or dementia paralytica.
Finally,
the delirium
Besides the treatment of the initial disease, the ice cap

should be applied to relieve cerebral hypersemia. Cold
baths or cold packs with friction are most serviceable.

In case of cardiac weakness one must be cautious in the
use of the bath, and
lant.
necessary administer a cardiac stimuFor this purpose strong coffee is valuable. Antiif
pyretics are not only useless, but often aid in producing and
One of the most important
intensifying the delirium.
constant attendance, both to prevent harm to

others and injury of the patient by escaping out of doors
indications
is
or jumping out of windows.
If
the excitement becomes
excessive, one should resort to the prolonged
warm bath
This measure rarely fails to bring quiet. In

(see p. 140).
addition, however, a clever, reassuring nurse is most essential.
The method
sheets so
of
much
in
applying
vogue in
pitals should be decried.
a prominent feature,
padded beds with high
it
and restraint
private homes and general hosIf
impulsive movements are
strait
may
jackets
be necessary to improvise
sides, or to resort to padded rooms.

The use of hypnotics and narcotics is harmful and distinctly
contraindicated. Furthermore, the proper use of hydro-
therapy usually renders their administration unnecessary.
INFECTION PSYCHOSES
B.
125
INFECTION DELIEIA
This group comprises psychoses which appear to stand

in intimate relationship to the specific toxaemia of certain
infectious diseases, including the initial deliria of typhoid
and smallpox and the deliria accompanying malaria, acute

chorea, and influenza. There are also grouped here deliria
that develop in some septic states, as well as those occurring
in toxic states of a less specific nature and presenting the
"
course of the so-called
Acute Delirium."
Initial Deliria.
the
infection deliria, the initial deOf
lirium of typhoid is best known. Nissl has reported on
the pathological anatomy in one case in which there was
distention of the vessels of the cortex, with increase of white
blood corpuscles and pronounced degenerative changes in

the nerve cells. The cell bodies were swollen, the chro-
mophiles were dissolved, and the processes diffusely stained

for some distance.
Karyokinesis was observed in nuclei of
These changes, which are similar to those

produced by experimental intoxication, tend to prove
that we have to do with a psychosis depending upon inthe glia
cells.
toxication.
l
Aschaffenburg distinguishes two forms of initial delirium
of typhoid.
In the first the delirium is not accompanied by
psychomotor activity, but there are numerous and pronounced

delusions, mostly of a threatening and
persecutory nature; such as, cursing voices, visions of fright-
hallucinations
and
ful and threatening forms, and ideas of poisoning and personal injury. The emotional attitude is usually one of
intense anxiety and sadness. The patients are often productive and relate adventurous experiences.
The
other form, which, indeed,

1
may
Aschaffenburg, Allgem. Zeitschr.
f.
develop directly from
Psychiatrie LII, 75.
FORMS OF MENTAL DISEASE
126
the
is characterized by great psychomotor

activity.
delirium usually develops rapidly with marked hallucinations, incoherent delusions, delirious confusion of
first,
The
thought, sometimes flight of ideas, also an intensely anxious

emotional state, together with senseless impulsive movements.
During the
initial
accelerated.
The
delirium the sleep is greatly disturbed,

and there is little appetite; on the other hand, there is
usually but slight rise in temperature, and the pulse is not
onset
may
recognition of the type of delirium at the

difficult by the absence of the char-
be rendered
typhoid symptoms, which may not appear until

the delirium is well established. Farrar 1 lays stress upon
acteristic
impaired associative activity, fallacious sense deception, with

developing delusions, disorientation, psychomotor excitement, and anxious affective states. He also calls attention
to certain prodromal symptoms, which may exist from a
few hours to many days, as, nervousness, insomnia, and
nocturnal restlessness, and believes that cases with a sudden
onset are more uniformly fatal and occur particularly in

individuals with a faulty heredity.
The initial delirium of smallpox usually develops between
the third and fifth days, and is characterized by a short
violent course.
The symptoms
are similar to those observed
in the initial delirium of typhoid, but are characterized
by
and violent conduct with a tendency to commit suicide, in which respect
one is reminded of the epileptic befogged states. Tremor
and convulsions sometimes develop. The symptoms suban even greater clouding
of consciousness,
side with the appearance of the eruption, but occasionally

extend over into the pustular stage. It rarely happens
that the psychosis passes over into a condition of dementia.

'Farrar, "On Typhoid Psychoses," Medical Reports of the Shepard
and Enoch Pratt Hospital, 1903. Vol. 1, No. 1, p. 42.
INFECTION PSYCHOSES
127
The
recognition of the smallpox delirium depends wholly

upon the fever, the physical symptoms, and circumstances
pointing to this infectious disease.
Another type
mental disturbance characteristic of

develop between the eruption and pus fever,
of
smallpox may
in which the patients present only vivid hallucinations of
sight and hearing, while in other respects they remain well
The
oriented, clear in thought, and orderly in conduct.
varied visions and voices simply annoy them without causing
much
effect.
The course in these initial deliria is frequently characterized

by
partial remissions during the daytime,
in
which the
patients continue somewhat clouded and do not wholly

regain insight into their condition. The duration of the
rarely extends beyond one week, and usually is
shorter.
The delirium usually clears with the onset
symptoms
much
of the fever, but
it
may
pass over into the characteristic
fever delirium.
The outcome
is
distinctly unfavorable, as forty to fifty per
cent, of the patients die.
The
infection delirium
accompanying malaria is distinctly

intermittent, either accompanying or replacing the fever.
It occurs most frequently in the tertian and quotidian forms,
and
rarely in the quartan. The delirium may appear only

in the early stages of the disease, during this time replacing
The symptoms develop suddenly,

marked anxious excitement with proconsciousness and a tendency to reckless
the fever for a few days.
and
consist of states of
found clouding of
All of these symptoms suddenly disappear after

a few hours' duration, and are followed by profound sleep,
from which the patient awakes with little or no memory of
violence.
the attack.
The delirium always responds
use of quinine.
readily to the
128
The delirium that accompanies acute chorea,

when associated with acute polyarthritis and
particularly
endocarditis,
seems to belong to the group of infection psychoses. It is

characterized by a clouding of consciousness with a peculiar
dreamy confusion of thought, some hallucinations and deluThese patients apprehend

sions and emotional irritability.
continue disoriented and
but
single impressions fairly well,
are inattentive and distractible. Their speech is characterized by monotonous disjointed sentences, in which they
occasionally weave incidental observations. While they may
hear voices calling, see strange visions, and express persecutory or fearful delusions, these ideas are not clear and are
never elaborated further. The emotional attitude varies, as
at times they are anxious, at others elated, and occasionally
show outbursts of passion.
This mental picture is accompanied by a condition of
almost constant choreic excitation, in which the characteristic choreic
movements continue
in
an exaggerated form
and also interfering
both day and night, preventing sleep

greatly with nutrition. The duration of the psychosis is
from a few days to a few weeks, and not infrequently terminates
fatally.
Other infectious diseases that may give rise to a delirious

state which apparently depends upon a toxaemia, are in2
In the first
fluenza, hydrophobia, and certain septic states.
apt to be clouding of consciousness, delirious hallucinations, confusion of speech, and anxious excitement.
there
is
Sometimes there
is
also present paralysis of speech
and
The
psy-
deglutition, as well as polyneuritic
symptoms.
Mobius, Neural. Beitrage, II, 123, 1894 Zinn, Archiv f Psy.

411, 1896; Krafft-Ebing, Wiener Klin. Rundschau, 1900, 30.
.
V,
XXVIII,
Hogyes, Lyssa, Nothnagel's Handbuch der Pathologic u. Therapie,
5, 88,
1897.
INFECTION PSYCHOSES
chosis
accompanying hydrophobia
In
a delirium in which
the
predominate.
septic states the
develop a delirium in which there are many
hallucinations
patients
is
129
may
hallucinations, clouding of consciousness with disorientation,

low and indistinct mumbling, and attempts to grasp at in-
At times the condition
visible objects.
is
one of pronounced
delirious excitement.
a group of cases which seem more properly

classified here than elsewhere.
It includes those delirious
Finally, there
states that
is
sometimes accompany furunculosis or follow a slight
angina, intestinal catarrh, obstinate constipation, etc.,

may occur in the course of any other type of
Some
psychosis, which suddenly takes a turn for the worse.
physical
illness,
or
would include
this particular type of delirium
with certain
marked excitement, and denominate them all

The delirium seems to arise from a
recent active infectious involvement of the cortex, as shown
in the pathological anatomy, by an acute destruction of
other states of
"
Acute Delirium."
the nerve
cells,
sometimes including
the
fibres,
in ad-
dition to an increase of the glia, and vascular changes

with diapedesis of leucocytes and occasionally an escape
of the blood corpuscles.
The patients become sleepless, bewildered, and distractible.

Numerous hallucinations of sight and hearing appear,
and incoherent expansive and persecutory delusions are
expressed. They prattle away, sometimes pray, and finally
be resolved into a repetition of a few senseless
words and syllables. Emotionally, they may be anxious,
speech
may
The
elated, or irritable.
activity
is
greatly increased
and
accompanied by impulsiveness, with pounding, dancing,
Food
rapidly.
usually refused and the patients fail

Temperature develops; and there appear ecchy-
moses or
fat
yelling, etc.
is
embolism, furunculosis, gangrene of the lung,
130
severe catarrh of the nose, gangrene of the mouth, sometimes parotitis and retention of urine and feces. In the
vast majority of cases the delirium runs a fatal course in

from one to two weeks.
An accurate
differentiation of this
alone upon the
The
symptoms
delirious states
is
form
of psychosis based
at present almost impossible.
which sometimes develop in paresis and
catatonia are recognized only by the previous history of

symptoms characteristic of these diseases antedating the
delirium.
Collapse delirium, which
tical toxic state,
may arise from an
iden-
can be distinguished only by the relative
the clouding is less profound, the

activity less turbulent, while the hallucinations and delusions are more vivid, and in the speech both distractibility
observations that in
it
and flight of ideas prevail.

The treatment of these different infection deliria depends
in some measure upon the treatment of the underlying
In view of the toxic origin of the disease
a thorough flushing of the body combined with infusion of
normal salt solution is excellent practice. One may employ
physical disease.
the prolonged warm bath (see p. 140) for relieving the motor
excitement. Sufficient liquid nourishment is always indicated, which
nasal tube.
may have
to be administered by stomach or
The bowels must be kept open, for which
purpose high rectal injection of normal saline solution may

be used twice daily. Furthermore, the mouth should be
cleaned by frequent swabbing.
In case medicinal sedatives
advisable, alcohol and paraldehyde are well recommended, but powerful narcotics and sedatives should be
seem
sedulously avoided. Failing heart action should be supported by the use of caffein, camphor, or ether.
INFECTION PSYCHOSES
0.
131
POST INFECTION PSYCHOSES
These psychoses are in general characterized by a more or

less pronounced degree of intellectual and emotional weakness, together with, in
most instances, pronounced delusion
formation and a prevailing sad or anxious emotional attitude.

postfebrile psychoses described here by no means in-
The
clude
all of
the psychoses appearing after the febrile period

The exhaustion psychoses as well as
in infectious diseases.
most any other form

this period.
The
of
first
mental disease
may
develop during
symptoms often, but not always,
appear before the fever wholly subsides.

The mildest form of postfebrile infection psychosis is represented by those cases in which after the subsidence of the
fever in a severe attack of infectious disease, the patients
show their former physical and mental energy. They

and sluggish, and are very susceptible to fatigue.
They cannot collect their thoughts, and find it difficult to
read and write, are indifferent, idly lie abed, and let things
go as they will. Orientation is undisturbed and there usually
are no hallucinations, although transient hallucinations may
appear after closing the eyes, when for a few moments they
fail
to
are dull
hear unintelligible sounds, see faint visions, or experience

peculiar bodily sensations which are interpreted by them as
grave symptoms. In emotional attitude they are sad and
troubled, sometimes irritable, and occasionally at night they
suddenly develop a state of great anxiety. They may at
times exhibit a distrust of their surroundings, transitory fear
of poisoning, hypochondriacal ideas,
and even delusions
of
may give rise to aggressive attacks and

attempts at suicide. In actions they are inclined to be reserved, sort of stupid, and reticent about their delusions.
persecution, which
Physically, sleep
much
reduced.
and appetite are poor and body weight
132
This mild form follows particularly influenza and polyarthritis,
and whooping cough
in children.
seen in tuberculous and choreic cases.
It is occasionally
After a duration of
a few weeks to a few months, improvement gradually sets in,

provided the underlying physical disease has cleared up.
This syndrome, although suggestive of chronic nervous exhaustion, may be differentiated from it by the fact that
the
symptoms
are
more severe and stubborn, and do not
improve under rest and relaxation.
Furthermore, there is
not the same clear insight that exists in chronic nervous
exhaustion.
second group of postfebrile infection psychoses
is
char-
by more pronounced symptoms; namely, prominent hallucinations, fantastic delusions, and active excitement with anxiety. When the symptoms first appear,
which is always during the febrile period, there is complete
disorientation with marked confusion of thought, and very
many hallucinations which may involve all of the senses.
After the temperature subsides and the symptoms of the
initial disease disappear, the patients gradually become
somewhat oriented and more composed, but the hallucinations and delusions persist. They still hear threatening
voices, see grinning faces looking in at the window, and
must get out of the bed and at them. Some one pulls the
bedding, the food is not genuine, they are poisoned, no one
acterized
do the right thing for them, etc. Emotionally,

are
they
dejected, anxious, and ill-humored.
Sometimes, in
of
outbursts
passion, they attempt suicide and become
is
willing to
They are apt to be obstinate, quarrelsome, conand

resistive.
strained,
Physically, there is faulty nutrition
and insomnia. As the appetite and sleep improve, the hallucinations and delusions disappear. The patients gain insight into their condition, begin to busy themselves, and
violent.
133
accustomed conduct, but for some time they

show an unusual susceptibility to fatigue, and
an absence of the wonted mental and physical energy, together with weakness of memory. A few cases never com-
resume
their
continue to
A fatal termination is rare,
and always due

some complication. The duration varies
from several months to a year. This form follows especially
typhoid, smallpox, articular rheumatism, and sometimes
pletely recover.
to exhaustion or
develops during tuberculosis.

In adults, there may be some difficulty in differentiating
this condition from melancholia of involution developing
during an attack of some infectious disease. It, however,

may be distinguished by the greater prominence of hallucinations, the predominance of delusions of persecution over
self-accusations, and the great irritability in contrast to the
anxiety of the melancholiac. It may be differentiated from

dementia prcecox by the greater affect and disturbance of
apprehension and orientation at the onset of the disease,

and by the absence of negativism and stereotypy; from the
depressive phase of manic-depressive insanity by the absence
psychomotor retardation.
third and severest form of postfebrile infection psychosis is characterized by a severe delirium which soon passes
over into a condition of stupor. In spite of improvement in
of
The
the physical condition the patients continue dull, and incapable of perceiving and elaborating external impressions, and
have poor memory and judgment. Emotionally, they are indifferent, sometimes peevish.
They may be quiet or child-
They lie abed unable to take their food or

themselves, and have to be petted and handled like
ishly restless.
care for
small children.
and
Physically, they fail markedly in nutrition,

occasionally give evidence of severe cerebral disorder,
ashemiplegia, disturbance of speech, and epileptiform attacks.
134
The prognosis is dubious, as after an extended course of many

months only one-half of the cases recover. The other cases
improve gradually but present as residuals, weakness of
will-power, poor judgment, forgetfulness, poverty of thought,
and apathy. This form follows chiefly typhoid fever, and
sometimes malaria. It may be distinguished from the stupor
of the catatonic state by the absence of negativism, and from
the stupor of the manic-depressive by the absence of retardation and the presence of faulty memory.
The
treatment of all these three types of postfebrile infection psychosis is mostly symptomatic, with very careful
and cautious watching.
nursing, rest in bed, nutritious diet,

Still
another group of postfebrile infection psychoses
is
"
Cerebropathia psychica toxamica," which was first

"
1
described by Korssakow
Psychosis,"
(Korssakow's
"
"
Neurocerebrite
Polyneuritis Psychosis,"
Toxique").
It is characterized by a pronounced disturbance of that element of memory which we call impressibility also by disorientation and the physical signs of polyneuritis, associated somethe
times with a delirious excitement or stupidity.
The symp-
toms
of this form of polyneuritic psychosis are very similar to

the alcoholic polyneuritic psychosis (see p. 184), and can be
distinguished only by their more prolonged course and the
The duration of the

history of the underlying physical state.
psychosis extends over many months, in case death does not
and the outcome is rather more favorable than in the
alcoholic cases.
The treatment is practically the same as
occur,
that outlined in the other forms, with the exception that

some attention must be paid to the muscular atrophies,
1
Korssakow, Gazette russe hebdomadaire clinique, 1889, No. 57

Meyer in Raecke, Archiv f. Psych., 1903, Bd. 37, H. I; Turner, Jour, of
Ment. Sci., October, 1903; Miller, Am. Jour. f. Ins., LX, No. 4, 1904;
;
Frie
ftnder,
Monatschr.
f.
Psych., VI, 4491
Raimann,
idem., XII, 329.

which demand the use
of electricity
135
and massage
after the
subsidence of the acute neuritic symptoms.

There is still another form of postfebrile infection psychosis, different from any of the preceding forms, which is
characterized
by the sudden appearance
ment with clouding
of active excite-
of consciousness, flight of ideas,
and
fantastic expansive delusions, simulating the symptoms of

the expansive paretic. Following a few indefinite prodromal
symptoms there appears
first,
usually during the febrile
period, considerable restlessness, then disorientation, distractibility, and hallucinations of sight and hearing, and
finally the
also
most elaborate grandiose
fabricate
extensively.
delusions.
The patients
Emotionally, they are some-
sometimes elated, but always changing

from
one
state to another.
There is absolutely no
rapidly
In addition, the patients are productive and show
insight.
times irritable,
a flight of ideas with a tendency to rhyming. The restlessness is so great that they cannot remain in bed.
Little food
taken, sleep is scanty, and nutrition suffers greatly. This
form follows typhoid. In part of the cases the course is rapid
and the outcome favorable. After some months the excite-
is
ment and the
delusions gradually disappear. The patients,

continue
to be irritable, susceptible to fatigue, and
however,
upon
ideas
slight
mental application easily develop again
and delusional
acteristic
silly
established.
ensues.
fabrications,
elation
flight of
and may show a char-
even when convalescence
is
well
In a considerable number of cases dementia
This form
may be
distinguished from paresis
by the
absence of physical signs. The treatment consists mostly of

continued rest in bed, prolonged warm baths to alleviate
the excitement, a nutritious diet, and very careful nursing.
EXHAUSTION PSYCHOSES
II.
THE exhaustion psychoses, collapse delirium, amentia, and

chronic nervous exhaustion, include those forms of mental
disease that seem to arise from excessive exhaustion or insufficient restoration of the
The term
"
nervous elements in the cerebral

"
is most applicable to those

that
follow
a severe and radical
immediately
psychoses
of
the
such
as that produced by
change
physical organism,
cortex.
exhaustion
acute diseases, excessive loss of blood, and childbirth. But

even here one cannot always exclude the possibility of a
toxaemia arising from an infectious organism or from the
result in
cribed
the
case
in the
it
to
more accurate knowledge may

these forms being grouped elsewhere and as-
destruction of tissue.
other etiological factors.

This occurred in
"
of
acute dementia," which is now classed
group
of
represents a
post
psychoses, except when

catatonia or manic-depressive
infection
phase in
insanity.
and amentia, though they run a slightly

many symptoms in common; namely,
a profound disturbance of apprehension and of the coherence of thought, as well as hallucinations, flight of ideas, and
psychomotor excitement. Exhaustion arising from more
prolonged mental and emotional stress, or extended
physical illness, produces the less acute but more chronic
Collapse delirium
different course,
psychosis,
have
chronic
nervous
exhaustion
thenia).
136
(acquired neuras-
COLLAPSE DELIRIUM
A.
This psychosis
profound
characterized
is
clouding
137
by an acute onset with
consciousness,
of
great
incoherence
of
thought, dreamy hallucinations, a changeable emotional attitude, and great psychomotor activity, a rapid course, and a
fairly favorable prognosis.
Collapse delirium is a rare form of insanity.

the exhausting conditions giving rise to it, childthe most prominent; others are loss of blood, exces-
Etiology.
Among
birth
sive
is
emotional shock, and deprivation with

The acute diseases which may lead to this condi-
mental
anxiety.
tion are
strain,
pneumonia and
erysipelas.
occurring while the patient

the exciting cause.
is
in a
Oftentimes a fright
weak condition
acts as
Unfortunately but few cases
have been examined pathologically. Alzheimer, 1 in a case
which seems to belong to this group, found throughout the
cerebral cortex a fine granular disintegration of the chromatic substance, and without much involvement of the
nucleus or increase of
glia.
Following a few days of insomnia and

the
restlessness,
patients rapidly become disoriented and
everything about them seems changed and unnatural.
Symptomatology.
Numerous dreamy
illusions
and
hallucinations appear; the

the form of threatening figures,
designs on the carpet assume

gas light appears like the sun, neighbors pass to and fro,
beautiful music is heard, and patients pass through all sorts
of
dreamy experiences.
They become very talkative, the content
ing great incoherence with a

1
Wanderversammlung
Baden-Baden, 1897.
d.
of speech show-
flight of ideas,
suedwest
Neurolog.
u.
many
allitera-
Irrenraetze
an
138
tions,
rhymes, and repetitions, which
as spoken.
Numerous
incoherent, changeable,
In
may
be sung as well
delusions are expressed which are
and both exalted and
emotional attitude patients are
much
depressive.
exalted and some-
;
depression with anxiety, however, may pretone.
emotional
the
dominate
Occasionally there is irrita-
times erotic
bility
with exhibitions of passion.
The motor excitement is very pronounced; patients remove their clothing, race about the room, overturn furniThey are both destructive and
ture, and pound the door.
untidy, and often exhibit the most reckless and impulsive
movements.
They
prattle
away
incessantly, sometimes in
now at the top of their voice, and again gesticuand

clapping their hands. The attention cannot be
lating
attracted and questions are rarely answered. They will not
a whisper,
obey requests, but almost always exhibit a purposeless

resistance to everything, even to bathing and dressing.
There
great insomnia. If the patients

Likewise they take
sleep at all, it is only for short intervals.
but little nourishment, and in many cases require mechaniPhysically.
is
The condition of nutrition is wretched, and

a marked loss of flesh and physical weakness. The
skin is pale and clammy, the temperature usually subnormal,
and the pulse weak and irregular. The reflexes are usually
cal feeding.
there
is
exaggerated.
Tremor
is
sometimes present and there
is
tendency to acute decubitus.

The duration of the disease
Course.
of only a
is brief, sometimes
few hours or days, and rarely lasting over one to
The return to consciousness is usually sudden,

often following a sound sleep. When the patients awaken,
the hallucinations and illusions have disappeared; they are
two weeks.
conscious of their surroundings and ask for nourishment.

They may continue talkative, perhaps showing a flight of
ideas,
139
exaltation, grumbling, and fretful manners for

and even days. Brief relapses sometimes occur.
some
several hours
As soon
as nourishment
is
freely taken, the weight increases
rapidly.
The
Diagnosis.
differentiation
from infection delirium
has already been considered (see p. 130). The epileptic befogged states are distinguished by the greater clouding of
consciousness, a more uniform emotional tone which is
mostly anxious or ecstatic, and the fact that the activity

does not conform to the thought or the emotional expressions.
The
orientation,
The
by the clearer
catatonic movements.
catatonic excitement is recognized
and the
characteristic
delirious excitement of dementia paralytica
can be
dif-
by the history of preceding mental deterioraand the presence of characteristic physical signs. The
delirious mania of manic-depressive insanity, in the absence
ferentiated only
tion
of a history of previous attacks, can be recognized only by

a greater disturbance of apprehension and the very vivid
Amentia
hallucinosis.
and
if
is
differentiated
by the longer course
distractibility of the attention.
Prognosis.
Recovery from the mental disorder
the patients do not die from collapse.
Treatment.
tain nutrition
is
usual
The important indications are first to mainand next to alleviate the excitement. The
patients must, therefore, receive a sufficient quantity of

liquid nourishment, in the
accomplishment of which
it
is
often necessary to resort to forced feeding by stomach or

nasal tube.
little alcohol (one to two ounces) added to
the milk and egg is extremely valuable. Broths and peptonized meats may be given in small quantities. Where
mechanical feeding is contraindicated, because of vomiting or
abrasion and hemorrhage of the mucous membrane, nutrient
enemata can be substituted.
Failing in this one can always
140
resort to the hypodermoclysis of
to
normal
saline solution,
one
two pints, with the expectation of securing excellent re-
sults, especially if there is
impending
collapse.
The
infu-
sion should be given under low pressure in the back, rump,
or breast.
In the alleviation of the excitement, by far the most efficient remedy is the prolonged warm bath, into which the
patient should be placed at once
and kept there
until the
The bath should be maintained at

The
all the time.
patients may remain in the bath without fear of harm for
hours and even days at a time, but usually they become
quiet in less than an hour, when they should be returned
to bed. As soon as the excitement reappears, they should
excitement subsides.
ninety-five to ninety-eight degrees F.
again be placed in the bath. If the patients exhibit fear

in entering the bath and require holding, the bath can do
but
little
injection
good.
In such
of hyoscine
cases,
one
may
hydrobromate,
trional, 15 grains, shortly before the
As soon
give a hypodermic
to -$ grain, or
-^
bath for the
first
few
become accustomed to the

bath they usually like it, and some even fall asleep in it.
If the bath is not available and one must resort to hypnotic and sedative drugs, hyoscine hydrobromate -^ to
grain and paraldehyde forty-five minims to one drachm
may be relied upon for the best results. / One should not
be persuaded to overload the system with sedatives in an
effort wholly to subdue the excitement in the hope of securing quiet for others. \ Excitement, of itself, is by no means
the most serious symptom. It is sufficient if you succeed in
procuring even a few hours' sleep and prevent the patients
from wholly exhausting themselves. Prolonged warm baths
times.
as the patients
properly applied usually render unnecessary the use of

If the patients collapse, hot coffee by mouth or
sedatives.
141
rectum, strychnia, dignitalis, or hypodermic injections of
camphorated
oil
are indicated.
be isolated in a quiet place, with

attendance to control them at all times. Constant
It is best that the patients

sufficient
attendance must be enforced in order to prevent injuries,

and this must be observed until convalescence is well established.
Mechanical restraint should not be employed; a
padded bed or room is preferable. During convalescence

the same indications obtain here as in convalescence from
any acute disease careful feeding, graduated exercise, and
freedom from all forms of excitement. Finally, one must
:
be assured of complete recovery before the patients are permitted to resume their usual occupation or responsibilities.
A good index of this is found in the weight, which should
always return to normal.
B.
ACUTE CONFUSIONAL INSANITY (AMENTIA)
This form of exhaustion psychosis
is characterized by the
and hallucinations,
illusions
numerous
rapid appearance of
motor
and
excitement, with a
clouding of consciousness,
duration of two
Etiology.
to three
months.
The conditions
of exhaustion giving rise to
amentia #re chiefly childbirth, also acute illnesses, excessive

loss of blood, excessive mental strain, and night watching.
An emotional shock may be the final exciting factor. Women

are
more frequently
affected than
men.
Cases of amentia
represent about one-half to one per cent, of the admissions to

hospitals.
Symptomatology.
less,
and
forgetful,
At
first
the patients are anxious, rest-
sometimes complaining of numbness and
confusion in the head, and inability to gather their thoughts

or concentrate their attention.
In the course of a few days
disorientation appears; the surroundings
seem changed, and
142
they do not recognize relatives.
Hallucinations of the dif-
They see strange faces and hear

are
birds
strange voices,
flying about, lions are roaring,
poisonous powder is thrown at them, and they are threatened
ferent senses appear.
and cursed by
form the basis
strangers.
The numerous
hallucinations
depressive delusions, which are

dreamy, incoherent, contradictory, and often repeated.
Their children are dead, the home is lost, they are to be
for
many
hung, are under the influence of some magnetic power which

draws them about, and in the end will consume them. In
a few cases the delusions are expansive; they then believe

themselves exalted to some high position, possessed of great
wealth, or they have journeyed around the world.
will convene Congress, and send an army to Cuba.
They
They
sometimes fabricate extensively.
The
by the surroundings and the

to
endeavor
what
It is usually
patients
grasp
transpires.
attention is attracted
possible, also, to direct the train of
before them,
by movements and
thought by objects held

gestures; but they under-
stand readily only the simplest occurrences. Some patients

claim that everything is changed, things are not genuine,
the chairs and windows are not the same to-day as yesterday, the thermometer is not correct, the clock is not right,
and the papers are
Often the patients

incorrectly dated.
appreciate this inability to understand things, and complain
"
that they cannot "think right
or that some one "has made
them
crazy."
There
marked
disturbance of the train of thought. The

patients are unable to complete one idea before others inis
terrupt, producing a flight of ideas.
Words and sounds
caught up from the surroundings find a place in their expression, though not necessarily influencing or directing the
train of thought.
The speech
is
sometimes made up of
143
and disjointed words and phrases. Occaand rhymes are heard. In spite
associations
sound
sionally
of distractibility and flight of ideas, one occasionally finds
single, incoherent,
the patients holding to single indefinite ideas, usually of

persecution. The consciousness is much clouded. The persistence of clouded consciousness, with difficulty in arrang-
ing the impressions and ideas, is a characteristic and striking

feature during the intervals when the patients are quiet and
present a normal emotional attitude.

The emotional attitude varies considerably, sometimes with
prevailing happiness, but more often with depression. Alternations of the attitude are characteristic; for short periods
the patients may be elated, and hilarious, with perhaps

some sexual excitement, when they suddenly become excited
and irritable, or they may even be dull and stupid.
In the psychomotor
field there is
a marked pressure of
They move about restlessly, crawl in and out of

activity.
bed, destroy clothing, pound and beat, but the movements
are not very quick, are performed without display of much
energy, and are planless. The motor excitement is distinctly intermittent, there being intervals of complete quiet.
The sleep is much disturbed, the appetite is

and
there is complete refusal of food. The
sometimes
poor,
body weight falls, but the condition of nutrition is better
than in collapse delirium. The deep reflexes are increased,
the pulse slow, and the temperature subnormal.
Course.
The height of the disease is usually reached
within two weeks, during which time there may have been
Physically.
remissions of a few hours or even a day with clear consciousFrom

ness, insight, and disappearance of hallucinations.
this time the symptoms present characteristic fluctuations.
The more active symptoms may disappear, and the patients
become more coherent in speech, when again they develop
144
Genuine improvement develops gradually.

have become clear, long conversations or
Even
letter-writing tend to create confusion. In the lighter cases,
which are the more numerous, even after the patients have
excitement.
after they
become quite
clear,
the emotional attitude
may show
slightly elated or depressed condition, as seen in hyperactivity and garrulity, or distrust, anxiety, and irritability.
The
from three to four months. In the

severer cases, lasting some months, even when the patients
have become clear, a few hallucinations may persist for a
short time, and occasionally indefinite and transitory exentire course
is
pansive or depressive delusions are expressed. The patients

may appear unnatural and irritable and show outbursts of
Even
passion.
after all the
symptoms
of the disease
have
disappeared, the patients are very apt to show increased

susceptibility to fatigue, while for many months emotional
shocks or injuries are prone to create relapses.

rises rapidly
The weight
during convalescence.
Diagnosis.
The manic form
of manic-depressive insan-
ity
distinguished from amentia by the fact that there
is less disturbance of apprehension than of the psychomotor
sphere; in the manic state, in spite of great motor exciteis
ment, the patients usually give evidence of at least a partial

comprehension of the environment. Again in amentia the
movements are
slower, more planless, and less precipitous,

in
and,
quiet intervals, when there is no activity, the patients
are
still
hazy and confused.
The condition
of catatonic
distinguished by the fact that the catatonic

in
the
midst of the greatest excitement are usually
patients
able to comprehend their surroundings, to reckon time
excitement
is
correctly, to recognize persons,
and to record some passing
events. The amentia patients even during quiet are somewhat disoriented and fail to recall passing events. Further-
145
more, the characteristic catatonic features are absent. To

be sure, catalepsy and automatism may be present, but
genuine negativism, verbigeration, stereotypy, mutism, and
mannerism are absent.

Death rarely occurs except as the
Prognosis.
result of
collapse during the intense excitement at the

or
onset,
precarious physical conditions; as, heart failure,
suicide, of
sepsis,
and
phthisis.
The
patients almost
always fully
recover their mental health.
Treatment.
The
indications for treatment are identical
with those in collapse delirium; namely, maintenance of

nutrition and the alleviation of the excitement (see p. 140).
On
account of the great tendency to relapse, one should be

extremely careful about allowing the patients to enter an
environment in which they might be subjected to an emotional shock.

For this same reason, one cannot resist too
long the entreaties of the patients and their relatives that
they be allowed to enter their accustomed life, before they
have regained their normal weight, the menses have reappeared, and the emotional attitude has become wholly
stable.
a.
ACQUIRED NEURASTHENIA
CHRONIC NERVOUS EXHAUSTION
ACQUIRED neurasthenia
power
is
characterized
of attention, distractibility, defective
by a diminished
mental application,
difficulty of thinking, an increased susceptibility

increased emotional irritability, and a great variety
to fatigue,
of physical
symptoms, mostly subjective, including hypochondriasis.

Acquired neurasthenia must be clearly distinguished from
the psychopathic states or congenital neurasthenia (see
No doubt there are many transitional states between
p. 155)
.
the two diseases, and especially where both defective heredThe difference
ity and exhaustion are prominent factors.
symptoms, their course and outcome, in individuals

free from hereditary taints, it seems, is sufficiently distinctive
to justify the restricted use of the term acquired neurasthenia.
The real nature of the disease has been most
Etiology.
in the
logically pointed out
by Mobius, who claims that there is a

from the effects of
kind of chronic intoxication resulting
exhaustion upon nervous tissue, corresponding in a measure

to the intoxication resulting from the prolonged excessive
use of alcohol.
offers
clearer
This view, certainly,

conception
of
the
is
helpful because it
and aids in
disease
distinguishing between those cases which simply involve an

accumulation of the effects of fatigue and those in which the
morbid hereditary and inherently impaired powers of resistance
The
with
play the essential role (congenital neurasthenia).
and extravagant manner of living,

and lack of sufficient and wholesome
rapid, irregular,
little
relaxation
146
147
sleep in individuals actively engaged in business or taxed

with the responsibilities of the household, is distinctively
characteristic
regions,
of the
American people in the temperate
and accounts
in our nation.
for the great prevalence of this disease

Besides excessive mental application, the
worry attendant upon responsibility
is
an important
factor.
On
the other hand, prolonged and excessive physical exertion is at times undoubtedly an important factor in producing neurasthenia, particularly excessive bodily exercise, as is
occasionally seen in sports, such as golf, rowing, basket
But of especial importance are our faulty methball, etc.
ods of living, with insufficient relaxation and improper

Moreover, considerable depends upon the
nourishment.
individual powers of resistance.

This is particularly applicable to that considerable group of individuals, who always
feel unequal to the demands made upon them and find
themselves quickly and completely exhausted upon any

strenuous effort.
Of the men, naturally those who are more talented,

better educated, and more active, are the individuals who
most often suffer from this disease. Indeed, it is a fact
worthy of note that great capacity for work is frequently
accompanied by greater susceptibility to fatigue. Women,
because of their weaker powers of resistance and their greater
emotional irritability, are more susceptible than men, particularly the
The
disease
overburdened mothers, teachers, and nurses.

may appear at all ages, but is most often met
between the ages of twenty-five and forty-five, the period of

life during which the
greatest mental strain occurs. At an
age it is seen in ambitious students who apply themselves too closely to studies without relaxation. Occasionally
earlier
symptoms, which
differ in
no respect from those described
here, develop after emotional shocks
and acute
illnesses,
148
especially influenza, childbirth, loss of blood,
The
"
nervous weakness"
cence from severe illness

haustion.
It is doubtful
and operations.
which appears during convalesonly in part due to simple exthe disease ever develops after a
is
if
fright.
Symptomatology.
and with
it difficulty
Prolonged
work
produces
of further application.
Up
fatigue
to a certain
which may be considered as a safeguard

against overwork, may be overcome by an increased exertion
of will power, which in long and fatiguing work gives rise to
degree, this fatigue,
"
a feeling of
increased effort." Associated with this there
soon develops a characteristic feeling of disinclination and
then a fagging of the

of overexertion
is
will,
relieved.
and when
this appears the
danger
While the increased exertion of
the will can for a time balance the effects of fatigue through
an increased expenditure of power, the effects of fatigue
ultimately gain the upper hand and force one to cease work.
The first indications of exhaustion are when, under certain conditions, the increased exertion of will continues for
some time in spite of the uncomfortable feeling of fatigue.
what happens when work is performed under intense

emotional excitement. The signs of fatigue, which call for
relaxation, either do not appear or are overwhelmed, and
work is prolonged beyond a permissible degree. This in
time leads, on the one hand, to an exhaustion of the available
supply of strength, which recuperates only very slowly, and
is manifested by a sort of prolonged weariness, which persists
after relaxation and is still present to some extent when
work is again undertaken. It also involves an increased
susceptibility to fatigue and a more rapid diminution of the
This
is
capacity for work. On the other hand, under such circumstances, the increased exertion of the will also persists and
brings with
it
an increased emotional
irritability.
149
Unfortunately, there are as yet no experiments on the

But we know
effect of prolonged overexertion on the mind.
from long experience,
that,, first of all,
the ability
to
con-
tinuously exert the attention fails. The patient is easily

distracted by little things and is inattentive. He is no
longer able to think clearly and sharply, and requires much
more time
for his
forgetful of
He
accustomed work.
names and
figures, so that the
be done over several times before he
is
is
also apt to be
same work has to
sure of his results.
His susceptibility to fatigue is greatly increased, and his

work is carried out only with constantly increasing difficulty,
requiring greater exertion
and more frequent
As the
rests.
result of this difficulty of work, the patient also loses the
wonted pleasure
in his occupation.
He
finds that
he
is
compelled to force himself to the work which he previously

performed with ease and pleasure. He, furthermore,
shrinks from new undertakings because of obstacles which
appear unsurmountable.
Under the
attitude also
influence of these conditions, the emotional
becomes changed.
The
patients
become
easily
flustered, are ill-humored, unreasonable, peevish, faultfinding,
and impetuous. Customary amusements fail to

please,^ and they become discontented with their occupation.
irritable,
Trifling affairs, like the
misconduct of a
child,
inconven-
iences at work, which normally would pass unnoticed, disturb

them for hours and even days, and may lead to impulsive
outbursts, which they later regret.
The
patients have not only a keen insight into these

defects, but also a tendency to exaggerate their symptoms.
They
assert that the
memory
is
fected, and that the judgment
symptoms
is
failing.
The
af-
physical
more strongly exaggerated, which aids in

misery. The excessive anxiety about their
are even
increasing their
becoming profoundly
150
condition
health leads to
of
hypochondriasis, in
which there
a characteristic symptom,
a tendency to pay undue
is
attention to any trifling symptoms that may be present.

They believe that they are suffering from some incurable
disease,
and
especially the one
most dreaded.
There
may
be some genuine disorder, but the real symptoms are greatly

enhanced by the attention habitually paid to them. Canker
in the
mouth
considered infallible evidence of syphilis,

a cloudy urine indicates Bright's disease, and a cough means
consumption. In the beginning these fears may not be conis
sidered in a very serious light, but when they interfere with

the livelihood of the patients they may lead to such feelings
of despair that the patients no longer hope for recovery,
make their wills, and not infrequently attempt suicide.

The appreciation of their incapacity creates a feeling
of reserve, timidity,
and a lack
of self-confidence.
They
cannot trust themselves in public and fear fainting upon

the slightest exertion. Associated with the loss of willpower, there should also be mentioned the tendency to
compulsive thoughts and impulsive acts, which sometimes

explain the suicidal attempts. Here are included the various phobias, which are fully described in the constitutional
psychopathic states. In the strife to overcome impulsive
ideas, the patients often reach
an emotional
crisis of
short
duration, with restlessness, wringing of the hands, crying

at suicide. These states
and moaning, and even attempts

are more apt to follow continued
longed
visits or
excitations, such as pro-
unusual noisiness.
Physical symptoms.
feature of the psychosis.
These form a very characteristic

Among the most important symp-
toms are headache, insomnia, general muscular weakness,

parsesthesias, cardiac and gastro-intestinal disturbances.
Cephalalgia, which appears early, may be expressed as a
151
headache, a feeling of numbness or a pressure in the head,

which interferes with work. This is usually situated over
the eyes or in the occiput, and increases with exertion until
it becomes unendurable.
It is more prominent in the morning
and passes
oft
Sometimes there is a
during the day.
if the head were held in a vice or
by
feeling of pressure, as
a constricting band. It may be associated with vertigo,

dimness of vision, roaring in the ears, or painful pressure
points in the scalp.
Insomnia
usually an aggravating
symptom from
the
The few hours
of sleep, obtained either immediately

or
in
the
retiring,
early morning, after hours of restless
onset.
upon
is
tossing, are unrefreshing
and disturbed by dreams.
In some
cases, there is an unnatural drowsiness which causes the

patients to fall to sleep at all times and particularly after
some
exertion.
General muscular weakness
is
always in
evidence; patients are always languid, and tire easily

walking or from slight muscular effort.
Both the
superficial
and deep
reflexes
may
upon
be increased.
Rhythmic twitchings are occasionally noticed, particularly

twitching of individual muscles and especially those of the
Moderate stuttering is sometimes complained of.
There is slight tremor of the eyelids and hands, but usually
eye.
a marked
tremor of the tongue. Subjective sensations, variously located, are prominent, such as parsesthesias
or feelings of formication in the trunk and limbs, also darting
fibrillary
pains and burning sensations.

The patients are usually alarmed by various cardiac sensations; such as a gnawing or burning sensation, palpitation
and precordial pain and pulsations in different parts of

the body. The pulse rate varies considerably and is easily
influenced by work or emotional excitement. Associated
with the cardiac disturbances or occurring independently,
152
there
may be vasomotor
disorders; as cold extremities, localblushing or abnormal dryness of the skin.
and
The appetite is
ized sweating,
and anorexia is frequent, but

the nervous dyspepsia, gastric and intestinal, is by far the
most prominent digestive disorder. When the stomach is
empty, there
is
variable
usually present a gnawing sensation which
is
quickly relieved by eating. Gastric fermentation, probably

due in part to deficiency of the digestive fluids, especially
hydrochloric acid, causes distention of the stomach, accompanied with discomfort and pain. Extending into the
borborygmus and
of which may be severe enough to
intestines, the fermentation gives rise to
colicky pains, the latter
The
digestion is usually not impaired sufficiently to create disturbances of nutrition, but in

severe cases it may even cause cachexia and anaemia. The
simulate genuine
colic.
usually constipated and the tongue coated.

Diarrhoeas are apt to appear for short periods, and may be
persistent for a considerable time.
bowels are
In the sexual
life
there
is
but in a few cases there

gence, although at the
more often a
is
loss of sexual desire,
a tendency to excessive indul-
same time patients may complain
impotence.
In those cases in which there
of
frequent recurrence, the

patients tend to become chronic invalids of a most distressing
type. They go the round of physicians, pass from one saniis
tarium to another, taking
all kinds of drugs.

Mentally,
in
into
a
of
which
all
state
thought centers
they pass
lethargy
about their own misery. All attempts at business are aban-
doned, and the cares of the household are renounced. They

betake themselves to the seclusion of a charitable institution
with
its
demand
freedom from annoyances, or if they remain at home,

the utmost consideration for every whim. They
have no thought for the maintenance of the family or ap-
preciation of the burden which they create.
demand for sympathy leads to prevarications
assumed contortions,
153
The
and
increasing
to various
in order to assure the physicians or
friends that they are in a critical condition.
The
daily
"
My God, doctor, I am dying

greeting from one patient was,
Just feel of my abdomen. Have you no compassion for a
"
A female patient remained in bed for years,
dying man?
!
and when received at the hospital from the hands of

a tender-hearted mother, had not had her hair combed
in two years, and one of her toe nails had grown to the
length of five
inches.
It is this
class of patients
who
eventually become habitues of morphin, cocain, chloral,

antipyrin, and other drugs.
Course.
The onset
of the disease
It may,
is gradual.
an
acute
illness, especially
however, develop rapidly, following
influenza and also childbirth. There is a great variation in
the prominence of the symptoms.
toward evening
is
characteristic.
daily
Under
improvement
stress of circum-
stances, the patients are usually able to pull themselves to-
gether for a special occasion, but the following day witnesses

an exacerbation of the symptoms. The course is often
protracted and the convalescence gradual.
The differentiation of neurasthenia
Diagnosis.
other forms of mental disease
is
from
of the greatest importance
bearing upon the prognosis and treatment.

place it is necessary to exclude organic disease
of the internal organs.
The diagnosis of neurasthenia should
because of
In the
its
first
rather be reached
by a process
of exclusion, after a
most
thorough physical examination.

The psychoses most apt to be confounded with neurasthenia are dementia paralytica, dementia prsecox, and melancholia of involution. The difficulties in dementia paralytica arise
only in the
first
stages of the disease.
Signs of
154
nervousness without definite cause in a
man
of healthy con-
stitution, appearing for the first time in middle life, should at

In neurasleast arouse suspicion of dementia paralytica.
thenia the alleged memory defect varies from day to day,

is easily corrected upon effort, and does not show the defective
time element which

ory in the paretic.
is
so characteristic of the defective
mem-
Neurastheniacs complain of mental im-
pairment, but are able to amend errors in writing and

speech, while the real mental defect in the paretic is unrecogrecognized, its extent is not appreciated. The
defect, therefore, in the work of a neurastheniac is quantiThe symptative, while that in the paretic is qualitative.
nized, or,
toms
if
of the neurastheniac ameliorate as the
that the evening finds
him
day advances, so
at his best ; on the other hand, the
awakens refreshed, and more capable, but

more
during the day. Again, the neurastheniac has
fatigues
a keen insight into his condition, and tends to exaggerate his
symptoms, but the paretic has little or no insight, or, if presparetic usually
ent,
he rather minimizes than exaggerates his symptoms.
The sensory disturbances
of the neurastheniac are mostly
The
subjective, while those of the paretic are objective.
of
should
of
the
characteristic
paresis
physical signs
presence
leave no doubt; such as, Argyl Robertson pupil, increased
myotatic irritability, ataxia in speech and gait, tremor of
the facial muscles and of the tongue, epileptiform or apoplectiform attacks, etc.
The depressive phases of the other psychoses, especially

dementia prcecox and melancholia, are distinguished with
difficulty, particularly where these psychoses follow some
acute disease, or appear in neuropathic individuals who have
succumbed in the struggle with more favorably endowed
associates.
While the neurastheniac is ill-humored and
irritable
because he appreciates that his mental ability
is
155
impaired, his emotional attitude becomes happier just as soon

as some external excitement or a jolly company allows him
to forget his troubles, or as soon as he is relieved of the responsibilities of his occupation, and can secure the benefit of
rest
and relaxation.
In the despondency of other psychoses
there develops a feeling of anxiety and sadness without any

good reason, which, under the influence of distraction, is
not only not alleviated but may even be intensified. The

diminution in the power of comprehension and the ill-humor
at the onset of dementia prsecox is recognized especially
by the dulness of the patient, his indifference to the future,
and sometimes
also
by the
senselessness of his hypochon-
driacal complaints.
Where the
external causes of exhaustion are comparatively

insignificant one naturally suspects that there is at the bottom a constitutional nervous weakness, which demands not
rest
and relaxation but
and occupation. While

drawn between these states,
exercise
very sharp distinctions cannot be
yet there are some symptoms in congenital neurasthenia

which are rarely, or to only an insignificant degree, found in
simple neurasthenia; namely, the great susceptibility of
the individual symptoms to mental suggestion, especially
the abrupt fluctuations of the emotional attitude, the anxious
states, and the lack of strength.
The prognosis in simple nervous exhaustion

as
regarded
favorable, but it depends upon the extent to
which the exciting causes can be removed, as well as upon the
Prognosis.
is
individual's powers of resistance.
Under proper treatment
most patients greatly improve, but the probability of

a return of the disease sooner or later becomes much
greater, if the patient must enter his old environment and
undertake the same responsibilities that lead to the first
breakdown.
The more frequent the recurrence of the
156
disease, the less liable
is
the patient ever to regain his
former health.
Where possible, it is the duty of the family

physician to bear in mind prophylaxis. Individuals who
are handicapped by a defective heritage must be well guarded
during their development, with due attention to moral and
physical hygiene. Later, when it becomes necessary to enter
actively into the severer duties of life, the limitation of mental application and physical exertion, together with the
avoidance of worriment and anxiety, must be constantly
Treatment.
kept in mind.
In the treatment of the disease after
the individuality of the physician
he must recognize and
utilize his
is
of
power
its
development,
prime importance;
of influence over the
patient in addition to various therapeutical agencies.

requires confidence in order to inspire the patient and to
him from
It
lift
morbid anxiety and depression. Isolation with

a changed routine of life demands immediate attention.
In the lighter cases a trip to the mountains or a sea voyage
to relieve the asthenic condition, or where this is impracticable, removal from the customary surroundings into a
quiet, restful, but attractive place, will accomplish the same
his
result.
Next, insomnia must be combated. Enforced rest in bed

with change of environment, removal of cares and relaxation,
and the establishment of a fixed routine usually relieve the
At any
one should not have to employ

sedatives until the patient has had a chance to react to the
new method of life. Before resorting to the use of drugs,
sleeplessness.
rate,
the simple hypnotic measures should be exhausted; such as,

warm liquid nourishment upon retiring, a hot bath, gentle
massage, etc. If it seems necessary to resort to drugs, then

employ the triple bromides in five-grain doses repeated every
half hour for five doses
if
necessary, administered
157
on
alter-
nate nights with trional, veronal, or somnos.

Hydriatics are of great service in this disease, the most
methods being the cold ablutions, the spray, the
serviceable
simple douche, and the dripping sheet. In the last method,

which may be carried out at home, after a cold ablution,
eighty-five to seventy-five degrees, the patient standing in
warm water,
or on a dry surface, with a cold towel about the

head, a linen sheet dipped into water seventy-five to fiftyfive degrees, is wound dripping about the patient, the nurse
same time applying friction until a thorough reaction

takes place. The douche, as carried out at bath institutions,
is of great value.
at the
In the more severe cases, the secret of successful treatment

lies in a well-regulated routine suited somewhat to the tastes
but requiring of all a definite amount

nourishment, mental and physical exercise, alter-
of the individuals,
of sleep,
nated with rest and relaxation, together with baths and outof-door life. All of this may be carried out under the supervision of a physician who is willing to spend time and thought
in attending to the details.
The relative amount of exercise
and forced rest must vary in individual cases. The anaemic

and debilitated who have been exhausted by long suffering
or the prolonged care of invalids, together with anxiety and
worriment, require forced rest for a few weeks with a full
nutritious diet, massage, and passive movements.
Others,
from the beginning, need graduated daily exercise, which
must be purposeful and suited somewhat to the tastes.
The diet, also, must depend upon the condition of the nutri-
Where indigestion or constipation exists, the usual

means should be used to counteract these conditions, always
giving preference to physical agencies. Electricity and
tion.
massage are of value, but only secondary to the above
158
methods.
Sometimes
local treatment is called for in cor-
recting uterine troubles, errors of optical refraction, or in

removing nasal obstructions.
Finally, the patient should not
be considered suitable for
you have placed her beyond the danger of

This involves on her part a thorough understand-
discharge until
relapse.
and requires
and working
Such training
ing of the conditions leading to her breakdown,

an inculcation of the correct principles of living
and an appreciation
of her
own
limitations.
should be established early, and throughout the period of

treatment no opportunity should be lost in impressing these
ideas upon her mind.
INTOXICATION PSYCHOSES
III.
THE term
intoxication psychoses is here used in a narrow

sense to include all psychoses arising from toxic substances
taken into the body.
They
are divided into acute
and
chronic
intoxications,
according to the length of the time during which the toxic

substances have been ingested.
1.
The acute
ACUTE INTOXICATIONS.
intoxications are characterized in
common by
a delirious state of short duration, with pronounced psychosensory disturbance, dreamy fantastic delusions, pleasurable emotional attitude, often with conditions of ecstasy,
and without much motor excitement.

The number of toxic substances, including ptomaines,
which might be mentioned here is large. The transitory
character and the infrequency of the toxic deliria make
them of little importance to the clinician. They are, howof great scientific value to investigators, who are
able to study pathologically and psychologically the effects
ever,
of the different toxic substances.
are characterized
mentioned here.
form
is
Some
of
them which
by peculiar mental symptoms will be

The mental state produced by chlorohallucinations of sight only.
In
are hallucinations of sight in
appears yellow; hasheesh delirium is
characterized
by
santonin poisoning there
which everything
by disturbance of the taste and muscle senses.

Hasheesh and opium smoking produce a complacent feeling of well-being, and of a dreamy, pleasurable existence.
characterized
159
160
The
carbonic acid
narcosis
is
characterized
by
its
short
duration and the presence of pronounced sexual hallucinaIn the toxic condition produced by atropin there
is a severe disturbance of apprehension, with isolated hallutions.
marked confusion of thought, elated emotional

The course is
attitude, and active motor excitement.
either fatal or the psychosis clears very quickly with no
cinations,
recollection of the events.
The duration
of all these conditions is short,
from a
The prognosis dethe

of
the
In
intoxication.
pends entirely upon
severity
diagnosis one must rely in great measure upon the knowlfew hours to a few days at the most.
edge of the circumstances and upon the physical signs.

The treatment is limited to the employment of means to
rid the
body
of the toxic substance,
and the application of
special antidotes.
The psychosis produced by lead poisoning, encephalopathia saturninia, is more frequent and differs from the
above delirious states by its longer duration, characteristic
nervous symptoms, and poorer prognosis. The physical
symptoms usually precede the mental disturbance; that is,
wrist drop, peroneal paralysis, tremor, pains in the limbs,
and sometimes colic. The immediate prodromes are restlessness
and headache.
The onset
of the delirium
may be
There are many hallucinations of sight

hearing, great psychomotor disturbance, many delusions
with great fear, and complete clouding of consciousness.
acute or subacute.
and
The speech
incoherent, and in the height of the delirium there are frequent reckless impulsive movements.
There
is
is
complete insomnia, and very little nourishment

taken. The active excitement is followed by a condiis
tion of stupor or coma, sometimes antedated
excitement.
by stupor with
INTOXICATION PSYCHOSES
161
Epileptiform convulsions may also appear, and amblyopia is frequent. The convalescence is gradual, extending over several weeks. Some cases terminate fatally in
coma. While most of the patients recover, there are many
who, upon regaining clear consciousness, present a degree

of mental enfeeblement in which simple apathy is a prominent feature. A few present progressive muscular atrophy,
simulating dementia paralytica. The whole duration of
the psychosis in favorable cases is from a few weeks to three
months.
2.
OF
CHRONIC INTOXICATION
whose continued use leads

known and of most
Almost
clinical value are alcohol, morphin, and cocain.
all nations, according to anthropological data, have had a
the
many
toxic substances
to disturbances of the mind, those best
drug whose habitual use has been a source of danger to its

It is a striking fact that these substances have
people.
always been used first for medical purposes, and later continued for their exhilarating and alleged supportive effect.
A. ALCOHOLISM
The acute
intoxication of alcohol
is
described here rather
than under the acute intoxications, because of

association with chronic alcoholism.
Acute alcoholic intoxication produces at
first
its
close
a diminu-
and elaboration of exand

an
in the release
acceleration
impressions,
of voluntary impulses.
The perception of simple sensory
An attempt
is
difficult, sluggish, and uncertain.
impressions
to solve a simple problem shows a distinct diminution in
tion of the
power
of apprehension
ternal
intellectual power.
In speech one can discern that the association of ideas
most
closely related to the
prominent, such as the use of
The
release of
motor elements of speech is

compound words and rhymes.
motor impulses
is
much
accelerated so that
those expressions find utterance most readily that are most

familiar. The choice between two movements is precipitous,
frequently incorrect, and sometimes already executed before
the proper direction is determined upon. Later, or fol162
ACUTE ALCOHOLISM
163
lowing larger doses, the psychomotor activity is displaced by

paralysis, the rapidity and extent of the paralysis depending
both upon the amount taken and the susceptibility of the

individual. The muscular strength, at first slightly increased,
is
soon
much
diminished.
Even small doses
influence the capacity for good mental

not easily gathered, rendering the
are
Thoughts
solution of complicated problems very difficult. This in-
work.
creases
with the amount taken.
thoroughly intoxi-
man is unable to comprehend what is said to him

what goes on about him, cannot maintain his attention
He has no conception of
or direct the train of thought.
the significance or the bearing of his actions. The inter-
cated
or
nal association of the train of thought is very much disturbed, as indicated by the tendency to the repetition of
phrases and the use of commonplace remarks, also in the

fondness for quoting obscene rhymes and in the use of
jargon.
Finally apprehension may be so far lost that he
becomes insensible and unconscious.

the intoxicated state
Memory
of events of
is
very meagre.
In the psychomotor field, at first, there is a light grade
of overactivity, with the disappearance of the usual restraints which regulate the actions of our daily lives.
He
and jolly, speaks and acts without reThe ready release

straint, and even becomes reckless.
of motor impulses promotes the feeling of increased muscular strength.
Later the motor excitation increases;
is
active, gay, free
the facial expression loses its character, each action is

exaggerated; the voice is louder, and the smile broadens
He becomes profane, grumbles, and growls.

and
hasty
passionate, and a single word or a trifling
accident suffices to start a quarrel or to lead to an assault.
into laughter.
He
is
Finally the excitation, as the disturbance of apprehension
164
increases, is replaced
by
profound disturbance of
and there is a
speech, a staggering gait, and even
signs of paralysis,
complete motor paralysis.

The emotions at first give
way
to a feeling of well-being.
a certain degree of exhilaration, and freedom

from care. He becomes light-hearted and happy. Later
There
is
Higher moral feelings are lost. He

shameless, and because of the increased sexual excita-
irritability appears.
is
bility is often led to filthy excesses.
The duration
the individual.
though
ill
of the intoxication
depends much upon
It
usually disappears quite rapidly, aleffects may be observed for twenty-four to thirty-
six hours later: headache, lassitude, nausea,
and anorexia.
Fatigue predisposes to rapid appearance of paralytic signs,

even without the intervention of the period of excitation.
Individuals
who
and sleepy are apt

mischievous, and even
are rendered sluggish
also to be quarrelsome, aggressive,

cruel.
As the result of experimental investigations of acute intoxication in test animals, Nissl has demonstrated a profound
change in the cortical neurones, seen in the destruction of
many
in the fading
and the
irregular amalgamation
of the Nissl granules, the diminution in size and irregularity
cells,
whose membrane and nucleolus may finally

Dehio has observed similar changes in Purkinje
of the nucleus,
disappear.
cells.
CHRONIC ALCOHOLISM
CHRONIC alcoholic intoxication depends upon a chronic degenerative process in the central nervous system, and is
characterized by a gradually progressive dementia, with diminished capacity for work, faulty judgment, defective memory,
moral deterioration, occasional delusions, infrequent halluci-
and various nervous symptoms.

Defective heredity is an important etioEtiology.
logical factor, and is manifested by a diminished power of
resistance in the individual.
Some observers have renations,
ported as high as eighty per cent, of cases with defective

heredity, in at least one-half of whom the father had been a
Head injury, according to Moli, in twentycent, of the cases, has been regarded as a factor
chronic drinker.
two per
in producing lessened resistance to alcohol.
Male alcoholics
greatly predominate. At Heidelberg only six per cent, were

women. Hirschl, in Vienna, found among the male insane
thirty per cent, alcoholics and among the women only four
per cent, alcoholics. Alcoholism is more prevalent among
those who come in contact with it, especially the bartenders,
liquor dealers, brewers, and waiters. The extensive use of
alcoholic drinks by many classes of society and the laxness
of public sentiment in regard to it should also be regarded
as etiological factors.
Furthermore, the ignorance of most
people as to its proven deleterious effects is in a measure an

important element. There are thousands upon thousands
who
daily take a little beer, wine, or liquor because they are
"
does them good," and strengthens them.

In the brain, in advanced cases,
there is regularly more or less chronic leptomeningitis and
convinced that
it
pachymeningitis with or without hsematoma. The cerebrum is below normal in weight, its convolutions more or less
165
166
shrunken, and
its
ventricles dilated, the
in rare instances is granular.
and
The
ependyma
of
which
larger vessels at the base
in the fissures present arteriosclerotic patches or athe-
roma, but the most characteristic lesion
the endarteritis,
arteries of the
is
mostly localized, of the small terminal

cortex and other parts of the brain.
The cortical neurones
present a gradual
sclerosis,
called the
"
chronic
change
Nissl, in his experimental research with chronic

alcoholism, in test animals, found a moderate thickening of
of Nissl."
the pia, especially at the base, destruction of many of the

cortical neurones, with an increase of neuroglia, and besides
these other extensive characteristic cortical changes, the
meaning of which is still unknown. Alterations in the internal
organs
are
equally
prominent;
namely,
chronic
gastritis, cirrhosis of the liver, chronic nephritis, fatty infiltration of the myocardium, and chronic endocarditis with
greater or less degree of general arteriosclerosis.
There is a gradual and progressive

Symptomatology.
enfeeblement of the intellectual faculties. The capacity for
work
is first
to suffer.
The power
mental application
to maintain the attention,
of
becomes difficult
gradually
and the susceptibility to fatigue increases.
fails, it
New and
customed work requires unusual application and
is
unac-
accom-
plished only with difficulty Patients prefer to continue in the

same old ruts, and are indifferent in applying themselves to
.
any mental work. Consequently intellectual development not

only ceases, but retrogrades, showing an increasing lack in
judgment and a poverty of ideas, enhanced by a gradual failure of memory. Finally there is inability to acquire anything
new, important facts are forgotten, and the past is recalled
only as a somewhat confused and distorted picture. The
defects of judgment and memory offer a fertile soil for the development of numerous more or less pronounced delusions.
CHRONIC ALCOHOLISM
167
These delusions tend to show a striking lack of judgment, are

peculiarly ideas of injury, which sometimes take their origin
from isolated hallucinations, but more frequently from genuine perceptions which are falsely interpreted. In the
more severe cases, a condition of advanced deterioration is
reached.
Moral
a prominent and characteristic

a profound change in moral character,
deterioration
is
symptom. There is
and the patients soon lose sight
and the sense of honor. This
their
own
of the higher ideals of

is
life
especially noticeable in
estimation of their alcoholic habits.
They
dis-
regard their depravity with nonchalance, and claim that the

liquor, taken for their physical benefit, does them no harm.
When reprimanded for continued inebriety, they accuse a
friend of having given
are driven to drink
by
them the
liquor, or claim that they

their wives.
faithful promise to
abstain from further use of alcohol
may
be volunteered
but when encountered coming from a

saloon an hour later, he fails to show any feeling of
by an
habitue*
shame.
Some claim that their work necessitates stimulation;

others take only as much as can be regarded as a food. It is
of interest to note the variety of conflicting excuses offered
by mechanics for the necessity of taking liquor: the cook,
the fireman, and the iron moulder require it because of the
great heat; while the night watchman, the truckman, and
the iceman need it to keep off the cold. Many are driven
to drink
by unfortunate circumstances at home; the death

and an ugly wife are frequent
of a relative, a sick child,

incentives.
The
patients lose all affection for their families, become

indifferent to the tears of their children, have little interest
in their welfare,
disregard the real infidelity of their wives,
168
at the
same time developing a
certain exaggerated feeling of
self-importance, noticeable especially in conversation. They

are unable to take matters seriously, and display an un-
natural sense of humor,
drunkard's humor.
There is a corresponding increase of emotional irritability,

which is more evident during intoxication. Patients are
quarrelsome, engage in strife and abuse on small provocation, misuse their children, and are destructive of clothing
and
furniture.
Their complete and abject submission
when
opposed by a superior force or when incarcerated is in

marked contrast to their behavior at home. Their inoffensive behavior and attitude of humiliation before others
sympathy from the inexperienced.

They become entirely unstable, cannot remain at home,
visit from saloon to saloon, tramp from one city to another,
and engage in their usual occupation only for a few days or
often excites
hours at a time, offering the excuse that they are physically

unfit for continued labor.
They leave the support of the
family to the wife and children,
whom
they browbeat for

enough money to keep them in liquor. Others degrade
themselves by pawning clothing and furniture, and even steal
in order to satisfy their appetite.
Physically.
The most prominent
are: fine tremor, noticed
ments and
first in
physical symptoms
the more delicate move-
becoming general; muscular weakness with

atrophy; uncertainty in gait; defective speech, sometimes
thick, sometimes slurring, with occasional aphasic symptoms;
peripheral neuritis; frequent headaches and sometimes vertigo.
later
The tendon
reflexes are often increased, rarely lost.
there are frequently found areas of

hypersesthesia, anaesthesia, parsesthesia, as well as painful
pressure points. Epileptoid attacks occur in about ten to
In the sensory
field
thirty-five per cent, of the cases, usually during
an attack
of
CHRONIC ALCOHOLISM
169
delirium tremens or at the conclusion of a spree, but also

during the course of chronic alcoholism and even after more
or less prolonged abstinence. They occur mostly in persons

addicted to distilled liquors, and differ from genuine epileptic
attacks in that they are infrequent, but unusually severe,
while the absences, ill-temper, and befogged states peculiar
to epilepsy are absent.
Furthermore, the epileptic attacks

but
not
usually,
always, disappear with enforced abstinence.
In the sexual life there gradually develops, in spite of increased sexual irritability, impotency which often leads to
jealousy and fornication. Furthermore, the progeny is
rendered not only susceptible to alcoholism, but is particularly apt to exhibit evidences of defective physical and men-
development, and also epilepsy.

of the children of alcoholic mothers
tal
the
first
two years
of
life
The
is
rate of mortality
twice as great during
as of non-alcoholic mothers.
This
rate also increases with successive childbearing, reaching as

high as seventy-two per cent.
The chances of recovery depend upon the

Prognosis.
extent of mental deterioration and the character of the
treatment.
If the patients already
show moral
deteriora-
tion, prolonged treatment is apt to be of little avail; each

time they relapse into their former habits, becoming at last
mental and physical wrecks. Cases when taken early and

submitted to an extended treatment have a fair prospect
of complete recovery.
In many reputable inebriate institutions from one-fourth to one-third of their cases recover
permanently.
The recognition of chronic alcoholism preDiagnosis.

sents few difficulties in view of the history, the typical
and the physical symptoms, the latter being at times
made more evident by the presence of neuritic symptoms.
Treatment.
The successful treatment of chronic alcofacies,
FORMS. OF MENTAL DISEASE
170
holism demands complete abstinence from alcohol in every

form. A few patients are capable of carrying out this injunction successfully by themselves, but the vast majority,
and especially those whose occupation brings them into bad
associations, require the treatment afforded by a special
The
institution for alcoholics.
plan of treatment in the
impeded by the general
success of this or
chronic alcoholic
is
any other
materially
indifference of the environment
and
the attitude of physicians. Very many physicians, wholly

ignorant of the favorable results of treatment in reputable
institutions, injudiciously advise the friends that it is of
no use to waste money hi a long sojourn at an
Even
institution physicians are not
respect,
and
beyond
will force the patient's discharge
out of him."
institution.
criticism in this
"
as soon as
the patient himself does not

appreciate the necessity of treatment or because of delusions
resists any restriction of his liberty, then one must resort
the drink
is
If
to a legal commitment to an institution, which is

in many states even for a period of two years.
now possible
committed to your care the alcohol can be suddenly withdrawn, except in a few cases where
As soon
there
is
as the patient
is
a disturbance of the heart.
toms, insomnia, anorexia, and
which
The abstinence symp-
occasional
hallucinations,
arise in consequence of withdrawal, tend to quickly
disappear, and should cause no alarm. Improvement begins

If the patient
in a few days, and progresses gradually.
is received in a condition of drunkenness, ergot administered
and repeated every two hours, or

apomorphin given hypodermically, beginning with -^ grain
and repeated until vomiting sets in and the patient falls to
sleep, are remedies well recommended to ward off delirium
tremens and to restore the equilibrium of the patient. But
in fifteen-minim doses
for the benefit of the psychical effect,
it is
sometimes ad-
CHRONIC ALCOHOLISM
171
vantageous for the patients not to be relieved of all sufferSevere cases require a hospital residence of nine to
ing.
twelve months, or even longer. An index of the power of
resistance may be found in the patients' insight into their
own
condition,
and
willingness to prolong hospital treat-
ment.
In light cases it sometimes suffices to place the patient to

live in a family and community where total abstinence pre-
Even here it is necessary that the patient be kept

under close surveillance, especially during the first few
months. A similar arrangement is sometimes an excellent
plan to adopt for a time after discharge from an institution,
particularly where the patient has to return to an unfavorvails.
able environment.
cessful in the
Hypnotic suggestion has been very suchands of some physicians, both in establishing
a disgust for liquor and in creating will power to combat

the habit and withstand the enticements. Its employment,
if
successful, permits the patient to
remain at work and with
the family, rendering unnecessary a prolonged and expenMuch depends upon the per-
sive sanitarium residence.
sonality of the physician in charge of the patient or the

individual at the head of the family, who must inculcate
the principles of temperance and rehabilitate the powers of

A very important means for the assistance of
resistance.
the patient in his struggle against the alcoholic habit are
the various temperance abstinence societies, the most powerful of
which in
Upon
Temperance Abstinence
Church and the Good Templars.
this country are the
Society of the Catholic
the basis of chronic alcoholism, there develops a

psychoses namely, delirium tremens,
series of characteristic
Korssakow's psychosis, acute alcoholic hallucinosis, alcoholic

hallucinatory dementia, alcoholic paranoia, alcoholic paresis,
and
alcoholic pseudopareses.
DELIEIUM TREMENS
DELIRIUM TREMENS is characterized by the rather sudden

development of numerous fantastic hallucinations, mostly of
sight and hearing, indefinite and changing delusions, principally
of fear and often of a religious nature, with clouding of consciousness, restlessness, tremor, ataxic disturbances, with rapid
and good prognosis.
course
Etiology.
The
by no
In the greater number of
etiology of delirium tremens
means thoroughly understood.
is
cases excessive alcoholism appears to be the important factor,

though it is generally recognized that the disease may de-
velop in connection with an acute febrile disease or some

pronounced emotional excitement, as imprisonment and
injury.
Careful analyses of cases tend to
show that bodily
injury is really significant in not more than five to ten per

cent, of cases, while the disease, pneumonia, occurs far more
frequently (Bonhoeffer forty per cent.). It seems probable,

therefore, that in chronic alcoholics, any disturbance which
overtaxes the functional activity of the body or disturbs its

equilibrium tends to produce delirium tremens; thus, severe
chronic disturbances of the general nutrition are of great importance among the predisposing factors, such as that arising
which occurs in most cases, and prevents the

many weeks and even months.
Furthermore, the symptoms of delirium tremens in no way
resemble those of acute alcoholic intoxication, hence the
from
gastritis,
taking of sufficient food for
delirium cannot be due to alcoholic intoxication alone.
Again, the amount of alcohol ingested immediately before

the attack seems to bear no definite relation to it, as, in
some
cases, the patients
have had no alcohol for weeks;
withdrawal, and
In the
in some it appears in spite of continued drinking.
factors
of
other
delirium
tremens,
particular
development
others develop the condition only
172
upon
its
DELIRIUM TREMENS
173
must be at work besides the excessive use of alcohol. Just

what they are is not definitely known. It is believed that
the numerous and severe organic changes accompanying
chronic alcoholism play an important role and undoubtedly
produce, as shown by the poverty of the blood and abundance of adipose tissue, profound disturbances of metabolism.
Jacobson points to the presence of a decomposition material
in the intestine; Hertz places delirium tremens
basis as uraemia;
on the same
Elsholz finds blood changes indicative
of a particular auto-intoxication; and Bonhoeffer suggests

an intoxication arising out of the process of digestion, the
product of which is normally secreted by the lungs, which
particularly apt to develop when the lungs

diseased, as so frequently happens in delirium
intoxication
become
is
But the
findings in the blood and urine, which

result directly from the action of the alcohol or indirectly
through the fever, also the frequent occurrence of fever and
tremens.
mental picture, point conclusively

to the fact that in delirium tremens we have to do not only
finally the characteristic
with the simple increase of the chronic alcoholic intoxication,

but with an essentially different sort of an intoxication to which
a predisposing factor. The

occurrence of abortive attacks of delirium tremens,
the excessive alcoholism is only
common
preceding for some time the genuine attack of delirium

tremens, seems to distinctly favor this view, and to point to
the additional fact that in delirium tremens there is only a
sudden increase of disturbances which have been present

some time, but in a milder degree.
Male patients greatly predominate in delirium tremens.
According to Bonhoeffer seventy-four per cent, of cases occur
between thirty to fifty years of age. The disease occurs more
frequently in
summer than
in winter.
Besides a pronounced degree of
174
venous
stasis
and edema
ent, Bonhoeffer
finds a
of the brain,
which
marked degree
is
usually pres-
of fibre atrophy in
the radial fibres of the central convolution, in the fibretracts of the worm of the cerebellum, and especially in the
columns of Goll in the cord, while there is little or no alteration in the parietal or Broca convolutions; these lesions
are not found in simple alcoholism. In the large pyramidal
cells
and
in the
motor
cells of
the anterior central convolu-
substance is more or less

and the processes are markedly stained for
tions, the outline of the unstainable
completely lost,
a considerable distance.
observed.
number
Occasionally nuclear changes are

appear to be destroyed. A
of cells
similar condition prevails
among
the Pur kinji
cells.
Nissl
a partial destruction of the cortical cells,

change, which is suggestive of other acute cell
calls attention to
and
to a cell
changes, in which there is staining of the achromatic substance, especially the axis cylinder processes, vacuolization in
the
cell
substance and moderate swelling, besides chronic
cell changes and an increase of glia.

part of these changes
are due to chronic alcoholism, among which should be added
miliary hemorrhages, which in places occur in great numbers,
particularly about the nuclei of the eye muscles, as well as

In the internal organs there are
certain vascular changes.
found fatty degeneration and fibroid myocarditis of the heart,

cirrhosis of the liver,
the kidneys.
and acute and chronic
alterations in
Furthermore, Jacobson discovered in forty-
seventy-two autopsies an acute hyperplasia of the

in nine cases a hypersemia.
spleen,
Among the first symptoms to appear
Symptomatology.
are the sense deceptions; illusions and hallucinations of all
five of
and
the senses, but more especially of sight and hearing.

Bonhoeffer, Monatsschr. f. Psychiatric u. Neurologic,
Archiv f. Psychiatrie, XXXI, 3.
ner,
I,
These
229; Troem-
DELIRIUM TREMENS
175
during the day and annoy the patients conThey are perceived with great clearness, and with
stantly.
the terrifying content produce a marked alteration in the
appear at
emotions.
first
The
patients see
all sorts
of animals, large
small, moving about them; rats scamper about the
and
floor,
serpents crawl over the bedding, insects cover their food,

and birds of prey hover about in the air. These forms almost
always show more or
less active
movement, depending upon
the restlessness of the body and the eye movements. Double

sight is sometimes observed. This unsteadiness may in a
measure account for the frequency with which the flitting

and scurrying animals appear. Fantastic forms are seen,
mermaids, satyrs, and huge quadrupeds. Crowds press
upon them, troops
file
by.
The devil and his imps are

windows or crawling from
omnipresent, peering in at the
under the bed.
The patients hear all sorts of noises,
the roaring of beasts,
ringing of bells, firing of cannons, crying of distressed children. They are taunted by passing crowds, are threatened
with death, are cursed, called traitors, thieves, and murderers.
Parsesthesias of
the skin lead to the ideas that
ants are crawling over them, that bullets have entered the
body, and even the absence of wounds does not deter them
from exposing limbs which have been shot
full of missiles.
Hot
irons are being applied to their backs, and dust is

thrown in their faces. They can detect the odor of gas,
sulphur fumes are being forced through the keyhole. Real
room assume life; the tufts on the bedding

become creeping things, and the bedposts, demon guards.
The content of the hallucinations is not always of a terrifying nature. Sometimes angels are seen; beautiful music is
objects about the
heard.
God appears
Christs,
and
to them, announcing that they are

empowered to cast out devils; they are com-
176
manded
to go to confession and to proclaim the gospel

message; they are in beautiful surroundings, are richly
dressed, in palatial quarters, attended by lovely maidens.
Sometimes the scenes are of a lascivious character. Occasionally there is a mixture of the fearful and the beautiful,
but more often, when there is a change of the emotions, the
former
is gradually replaced by the latter, as the course of

the disease progresses. The hallucinations in a few cases,
and especially after the height of the disease has been passed,
are nothing more than a passing show for the patients; they
then gaze at the hideous forms and listen to the various
noises quite unconcerned.
The results of various experiments
seem to indicate that
the hallucinations and illusions originate in disturbances of

the central processes. Hallucinations seen through a
colored glass are not similarly colored. Also the hallucinations can be made to appear by directing the patient's
attention to their sensory
fields,
and by asking them what
they see and hear.
The various
hallucinations
may
enter into the picture of
an occupation delirium, when the patient is busy gathering

up the gold lying about him, driving a flock of sheep, leading an orchestra, or addressing an audience. On the basis
of these delirious experiences, the patients
may
develop a
whole fabric of delusions concerning their environment and

their experiences, but these delusions are never elaborated,
do not influence the thought or action to any extent, and are
quickly forgotten. There never develop delusional ideas in
reference to the personality of the individual. The patients
know who and what they are.

The process of perception in itself, according to Bonhoeffer, 1
always
does not present any very striking disturbances, the pain,

1
Bonhoeffer, Der Geisteszustand der Alcoholdeliranten, 1897.
DELIRIUM TREMENS
177
muscular and temperature sense of the skin, as well as the

acuity of sight and hearing and the measuring of distances
by the eye, being normal. The field of vision is sometimes
restricted, the recognition of color is uncertain,
tactile sensibility
The
on the
finger tips
and the
and the forehead
is in-
sometimes very greatly

disturbed, many patients being unable to sit up, to stand
or walk, and very anxious to remain in bed. This, he becreased.
lieves,
sense of equilibrium
is
accounts for the disorientation of the body in space.
Patients frequently complain that the floor is shrinking

and that the walls are coming together, which may be due
to disturbances of the eye muscles or of the labyrinthine
sense.
Disturbances of apprehension are prominent. There is

defective interpretation of the impressions excited in the
with the result that the patients misinterpret noises, do not recognize pictures, and are unable
various sensory
fields,
any sharp and clear impressions. The disturbance

becomes more apparent when the patients attempt to read.
to obtain
Instead of correct sentences, they read a senseless series of
words and sound associations, noticeable especially when

the type is small and indistinct. Sometimes there is no
relation at all between the reading and the subject-matter.
This same defect is sometimes due to aphasic disturbances.
The
shows marked disturbance. While it is

for instance,
possible to hold the attention for a moment,
to
a
to
at the
long enough
get
response
your reading test,
attention also
your efforts. The promakes the disturbance of

apprehension appear even greater than what it is. Forcible
next the attention
fails in spite of
nounced disturbance
of attention
hold the patients for a short time, but they

usually relapse, and they note only those objects that
especially attract them.
language
may
178
always a moderate clouding of consciousness. The

surroundings are not correctly comprehended, and the ideas
There
is
which are excited by occurrences in their immediate surroundings are confused and contradictory.
degrees of insensibility are
The
greater
found only in severe cases and
especially following epileptoid attacks.
On
the other hand,
profound disturbance of orientation, except in the

The surroundings are mistaken for the barlightest cases.
the
room,
church, or the prison, and strangers are greeted
there
is
as old friends.
Time
the duration of the
orientation
is
also incorrect.
Usually
seems to the patients much
illness-
prolonged, even to months.
The memory
for
remote events
is
The
well retained.
patients recall correctly where they live and facts concerning their families and occupation, and the length of time
they may have resided in different places. But the impressibility of the
memory
is
greatly impaired, as
may be
determined by giving the patients a series of words or numbers to recall later.

Memory for recent events is very
defective, especially as regards the temporal arrangement.
Fabrications of
memory
frequently appear.
The train of thought is mostly coherent, yet the patients

show considerable distractibility. The goal ideas are flighty
and not very well fixed. During a conversation trifling incidents or hallucinations
off into
may
various directions.
hinder the thought or lead
The
patients experience
it
diffi-
culty in collecting their thoughts, are unable to recognize

contradictions,
and
fail
in trying to solve problems
which
require thought.
In emotional attitude the patients are anxious and fearful
or happy and cheerful, depending upon the character of the
They may change rapidly from

laughter, and even indulge in witty re-
hallucinations or illusions.
intense fear to jolly
DELIRIUM TREMENS
179
and the fear of death may rapidly

and in this way there may develop a
mixture of concealed anxiety and humor, when it seems as
though the patients, in spite of the dreadful pictures and
fears, still recognize more or less clearly the humorous impossibilities and contradictions in their delirious experimarks.
Thus
elation
follow each other,
ences.
In actions the patients are more or less restless and

talkative.
They are seldom able to engage in work, though
occasionally a patient continues at his occupation until the
disease is well established.
Usually they take an active part
numerous hallucinations. They plug the ears to

out
keep
disagreeable noises, crawl under the bed to elude
persecutors, escape from the window to get away from the
in their
sulphur vapors and the enemies waiting outside the door;

they answer the imaginary voices, run to the station for
protection, or
amuse themselves with
their beautiful sur-
roundings and join in the happy company of imaginary
Sometimes they are assertive and aggressive, demanding attention or carrying out divine commands. When
in fear they sometimes commit assaults, but they rarely
revellers.
attempt
suicide.
Many chronic alcoholics develop what in their own parlance

"
is called a
touch of the horrors," which in reality is an abor1
tive form of delirium tremens.
Some of these cases come under
the care of the family physician, but the majority of them
go without medical attendance. The symptoms are those of
the prodromal stage of delirium tremens. During a debauch or following abstinence or mental shock, there develops
some parsesthesia, a vague feeling of fear, as if some one were
constantly behind the patients, the slightest noise causing
them to be startled. While in this state they have isolated
1
Berkley, Mental Diseases.
180
One patient saw for a

hallucinations of sight and hearing.
moment a number of rats scampering across the floor, others
were attracted by unnatural voices.
It very
frequently
happens at night that some object appears at the window

The patients are perfectly confor a second and is gone.
scious,
and appreciate
their condition.
Some
of the physical
tremens are usually present. The condiof short duration, rarely lasting over a few hours or
signs of delirium
tion
is
days.
Physically.
Besides the various sensory disturbances,
such as neuritic disturbances, parsesthesias, hypersesthesias,

and circumscribed areas of anaesthesias which may form the
and hallucinations, there is sometimes a

insensibility which will permit the patients to sustain
basis for illusions
lack of
There
severe injuries without complaint.
is
often present
great muscular weakness. The muscular movements tend

to be coarse and unsteady, and the gait uncertain and staggerThere is some ataxia and pronounced tremor of the
ing.
tongue and fingers, and sometimes of the extremities and
Speech is often ataxic and paraphasic, with maleyelids.
position of words and syllables, and in the severest cases
may be slurring and unintelligible. Occasionally in the
severe cases muscular spasms are noticed. Epileptiform
seizures are frequent, occurring mostly before the attack,
in ten per cent, of the cases one to
two days before the outand sometimes accom-
break, less often during the attack,
panied by transitory paralytic symptoms, such as hemiThe tendon reflexes are exaggerated. Insomnia is
paresis.
marked from the first, and persists unless the patients become stuporous. The condition of nutrition suffers, because
of the small amount of nourishment ingested, which is due
in part to the delusions of poisoning and in part to the
gastritis.
There
is
apt to be a slight
rise of
temperature
DELIRIUM TREMENS
during the
grees.
and
first
181
few days, rarely reaching one hundred derate is low as well as the respiration,
The pulse
occasionally there
is
profuse perspiration.
In a large percentage of cases the urine contains albumen

and casts, which clears up with the psychosis. Elsholz finds
in the blood a relative leucocytosis, with a diminution of the
eosinophiles at the height of the psychosis.

The duration of the delirium varies from a few
Course.
days to two weeks, rarely extending beyond three weeks.

The improvement comes with sleep. The hallucinations
usually fade away slowly, though sometimes they disappear
within a night. With the improvement of sleep the physical
gradually. The memory of the events
of the psychosis, in spite of great clouding of consciousness, is sometimes surprisingly clear, though it later tends to
symptoms disappear
fade.
show rapid
the improvement of sleep.
Not
all
cases
clearing
up
of
symptoms with
A few suffer a second attack

few days or even a week of clear consciousness
have intervened, and in spite of the fact that they have
after a
Others show a complete alteration in

the character of the psychosis after the hallucinations and
continued abstinent.
illusions
istic
have disappeared, some developing the character-
polyneuritis psychosis or the alcoholic hallucinatory

certain number of cases pass into alcoholic
dementia.
paranoia, to be described later.

In the more severe cases the physical signs become more
prominent and there develop convulsions, muscular twitch-
and disturbances of the eye muscles. At the

same time the insensibility and the incoherence increases,
the movements become weaker and the pulse smaller, and
finally death ensues, with sudden loss of consciousness or
ing, ataxia,
collapse.
182
The
Diagnosis.
diagnosis of the disease
is
not
difficult
known. Fever delirium

and the epileptic befogged states may be confused with
delirium tremens. In the former there is a more marked
if
previous history of alcoholism
is
clouding of consciousness, and, especially in the epileptic

condition, confused delusions of a religious character stand
moderate restlessness without impulsivethe

active
ness,
hallucinations, and the muscular tremor of
the alcoholic.
in contrast to the
The delirium
of dementia paralytica is differentiated
from
the alcoholic delirium by the previous history of change of

character, evidences of failure of memory and judgment,
and the more profound clouding of

a
with
consciousness,
change of personality.
The outcome is usually favorable. In the
Prognosis.
paretic physical signs,
unfavorable cases (three to nineteen per cent.) pneumonia is

the chief cause of death and greatly increases the fatality.
Other causes of death are cardiac

ing injury,
and
failure, infection follow-
suicide.
In warding
the development of delirium

tremens in chronic alcoholics who have suffered injury or
Treatment.
off
have developed pneumonia, one should withdraw the alcohol

at once and attend particularly to nutrition and sleeplessness.
Frequently repeated doses of ergot or the administra-
tion of
respect.
apomorphin hypodermically
The
first
(see p. 170) aids in this
indication for treatment
is
the establish-
ment
of proper nutrition, which requires frequently repeated

administration of small quantities of liquid. If necessary,
Gastritis with nausea
artificial feeding should be resorted to.
and vomiting may necessitate lavage. The second indication is to combat insomnia, for which purpose a combination
of 3J grains each of chloral, potassium, and sodium bromide
is most efficient, repeated every hour until sleep is secured.
DELIRIUM TREMENS
183
not permit the use of

chloral, paraldehyde or chloralmide may be substituted.
The patient should be confined in bed and watched con-
In case the cardiac condition
If
stantly.
will
excitement increases to such an extent that the
patient cannot be kept in bed, then the prolonged warm

bath must be employed (see p. 140). Great excitement may
necessitate its continuous use, combined sometimes with the
use of chloral and the bromides or paraldehyde, or in its
extreme
cases, the use of hyoscine.
As already indicated, alcohol should always be withdrawn.

In case the slightest evidence of cardiac weakness develops,
one should not hesitate to make use of caffein, camphor,
or camphorated oil, or in urgent states normal saline
infusion.
KORSSAKOW'S PSYCHOSIS
l
described a number of cases of apand associated with polyneuritic symptoms, which were characterized particularly by a profound
disturbance of the impressibility of memory, disorientation, and
a tendency to fabrications of memory. Later experience
In 1887 Korssakow
parent toxic origin
demonstrated that while this psychosis occasionally appeared

in connection with other toxic states (see p. 134), it developed
most often on the
basis of chronic alcoholism.
It also be-
came apparent that the polyneuritic symptoms are not a

constant accompaniment of the psychosis.
The intimate relationship of this psychosis to
Etiology.
Korssakow, Archiv f. Psychiatric, XXI, 669; Allgem. Zeitsch. f.
XLVI, 475; Tiling, ebenda, XLVIII, 549; Uber alkoholische
Paralyse und infektioese Neuritis multiplex, 1897 Jolly, Charite'annalen,
Psychiatric,
XXII; Moenkemoeller, Allgem.
Psychiatric, LIV, 806;

Wochenschrift, 1900, 2 Elsholz, ebenda, 1900,
Heilbronner, Monatsschrift f Psychiatric, III, 459.
Raimaim, Wiener
15 ;
Zeitschrift
klin.
f.
184
alcoholism has already been pointed out. Jolly regards it

as a severe form of delirium tremens, while Bonhoeffer deIt develops in
scribes it as a chronic alcoholic delirium.
It is
three per cent, of the cases of delirium tremens.
much more apt (eleven per cent.) to occur during the second
or
subsequent
attacks
of
delirium
tremens.
Women
appear to suffer in a proportionately larger percentage than
men.
There is an extensive destructive
process involving the nervous tissue from the cortex to the
peripheral nerves. The nerve cells present the usual signs
of an acute process while the nerve fibres give evidence of
varying degrees of destruction, especially in the region of the
central convolutions, when there is a prolonged course of
the disease. In the spinal cord there is an extensive atrophy
columns of Goll. Of parare

the
numerous
small hemorrhages, ocimportance
in
the central gray matter, where they are
curring especially
of the fibres, particularly in the

ticular
regarded as the cause of the oculomotor paralyses. The

acute hemorrhagic polyencephalitis superior, described by
Wernicke, according to Elsholz and Bonhoeffer, is frequently

associated with Korssakow's psychosis. The above anatomical lesions, which are indicative of an extensive destruction of nerve tissue, in reality are only what one would
expect to find in severe alcoholic intoxication.
The symptoms at the onset are similar

delirium tremens. But after the usual course of
Symptomatology.
to those of
the delirium symptoms, disorientation continues, while the

hallucinations, restlessness,
and insomnia disappear. The

and in addition there
delirious experiences are not corrected,
develops a very striking disturbance of impressibility of

memory (Merkfahigkeit). The symptoms sometimes follow
a rapidly developing stupor with hallucinations, and they
still
more
rarely develop gradually
185
from the chronic alco-
holic state.
In severe cases this disturbance of memory
is
so pro-
nounced that the patients cannot remember for a few minutes or even seconds that which they have just experienced.
They are conscious and understand what is said to them,
yet they are wholly unable to put together their recent experiences or to form any picture of the course of events in
They do not know what has happened in the

past hour, although in the meantime they have washed and
prepared for and eaten dinner and been visited by the
their lives.
physician, and, indeed, even if told all this, they cannot fit
it into their memory and correct the defect.
few very
striking impressions
may
be retained, but they are never
connected with the events immediately preceding or followThe first result of this disturbance of memory is a
ing.
complete loss of orientation. The patients have no conception of the time. They cannot tell where they are or those
about them, and usually greet the physician as an old acquaintance, though they cannot recall the name.
While the memory
is
more
particularly affected for events
since the onset of the psychosis, yet it sometimes happens

that there is a distinct loss of memory for events extending
back several months or even years. They cannot tell you

how they have been employed, or where they have been, or
have lived during all this time. Some forget that they are
married or have children.
called,
The
A few striking incidents may be re-
but the time of their occurrence cannot be established.
are not only not recognized by the

patient, but are very apt to be filled in with falsifications of
memory, which are related by the patient with a feeling of
lapses in
memory
absolute certainty. These falsifications may apply only to

the lapses of recent date. The patients then relate visits
186
which they have just had, or journeys which they have made,
and give a detailed account of the good times they have had,
while in reality for months they have been leading a wholly
uninteresting and monotonous existence. These fabrications can usually be drawn out by questioning and influenced
by suggestions. The fabrications are not always limited
to mere filling the lapses of memory with ordinary experiences,
but the patient
may strive to amplify the incidents with alto-
new and
gether
fictitious events.
This latter tendency is
pronounced only during the earlier stages of the disease.

Indeed, the fabrication may extend to an intricate and
fantastic falsification of the last ten years of the patients'
lives,
concerning which they relate
experiences.
all
The apparent accuracy
kinds of wonderful
of these fabrications
forcibly impresses one, together with the wealth of detail
and
the absolute certainty which they possess for the patient at

the time. Although the facts are frequently altered, each
time they are related as clearly and assuredly as if they had

occurred only yesterday. Occasionally, expansive and depressive delusions are added, but these also tend to change
rapidly and as suddenly appear and disappear. Some-
times hallucinations also occur at the beginning, which later

disappear.
The function of the intellect outside of the disorders
The
already
mentioned
patients
show good judgment on other matters, understand
is
not
facts presented to them,
and know how to
particularly
impaired.
answer questions to the point,
cleverly conceal the lapses in their
memory.
On
the other hand, they do not possess a clear insight into

their condition and are unable to employ themselves profit-
They can write letters well and carry out orders,

but they become shiftless and lead a thoughtless and in-
ably.
active
life.
187
The emotional
attitude at the onset is mostly anxious, but

becomes one of indifference and apathy, though
sometimes there is distrust and irritability, while in other
later it
cases a certain degree of good

Usually the emotional attitude
humor
is
or elation exists.
also easily
changed by
suggestion into one state or another.

The conduct and actions of the patients after the subsidence
of the delirium
become
orderly.
The
patients
may com-
plain a little about their surroundings, but they are mostly

As a result of faulty memory they are always
quiet.
neglecting to attend to personal duties, or repeating what
they have already done; hence the same questions are frequently asked, and numerous letters are rewritten. Delusions,
if
The
present, do not greatly influence the conduct.

physical symptoms are usually those of alcoholic
These, however, may be absent. The extent of

the symptoms also may vary considerably, but usually they
are confined to minor paralytic signs, atony and reduced
neuritis.
volume
Romberg
certain muscle groups, especially in the legs;

signs; sensitiveness of the nerves and muscles to
pressure;
more or
of
less extensive anaesthesia, parsesthesia, or
hypersesthesia; loss, seldom increase, of the tendon reflexes;

cystic disorders, some degree of ataxia; difficulties of
deglutition
and
and speech; and
paresis of the
facial
nerve
especially paralysis of the eye muscles (abducens).
The
pupils are often unequal, and notched, and sometimes do not

react to light. There is also tremor of the fingers, and fre-
quently a history of epileptiform attacks. Furthermore,

symptoms indicative of chronic alcoholism may be present,
as nephritis, hypertrophy, or atrophy of the
ascites,
and edema;
liver, icterus,
also faulty nutrition, anorexia,
and some-
times nausea.
Course.
Following the rapid development of the disease,
188
usually a long one. In some cases death ensues from paralysis of the heart or respiration. Not infre-
the course
is
quently a rapidly developing tuberculosis leads to death.

After a period of several months, there may be gradual
improvement, with disappearance of the neuritic symptoms,
a return of orientation and improvement of memory.

small
number
of cases the
improvement may,
In a
in the course
of five to nine months, be sufficient to permit the patient's
returning home, yet there regularly remains a considerable

increased susceptibility to fatigue, uncertainty of memory,
emotional apathy or irritability, weakness of will, and limited
Further indulgence in alcohol tends to quickly inUsually the disease tertensify these residual symptoms.
minates in a permanent dementia, which is particularly
activity.
characterized by the persistence of falsifications of memory.

The conditions of excitement at the onset of
Diagnosis.
the post infection psychoses may be differentiated by the fact

that clouding of consciousness is much more pronounced,
and hallucinations and illusions are more in the background;
absent, the emotional attitude
does not present the alcoholic characteristics, and finally the
Paresis is distinprognosis is distinctly more favorable.
further, the alcoholic
tremor
is
guished by the usual history of a gradual onset. Pronounced

neuritic symptoms with paralysis of the eye muscles and the
alcoholic tremors speak for Korssakow's psychosis, while
indications
aphasia, hesitating speech, marked paracerebral paralysis point to paresis.

Again, the
of
graphia, and
stupid or humorous emotional attitude of the alcoholic con-
trasts with the silly happiness of the paretic, while the only
intellectual disturbance of Korssakow's psychosis is seen in
the memory, which may not involve the more remote events
of life, as in paresis.
Presbyophrenia also is characterized
by impaired
impressibility of
memory,
loss of orientation
ACUTE ALCOHOLIC HALLUCINOSIS

and fabrication but
;
this disease occurs
189
mostly in the senile
may not be preceded by an alcoholic history, and is

not accompanied by neuritic disturbances.
Again, the
activity of the patients is greater; they are communicative,
period,
often garrulous, trouble themselves about the environment,

display a childish emotional state and a certain busyness,
The diagnosis may be difficult if the
especially at night.
presbyophrenic
been addicted to excessive
patient has
alcoholism.
During the early stages of the disease

the treatment is identical with that in delirium tremens
The alcohol must be absolutely withdrawn,
(see p. 182).
Treatment.
and the patient placed
either in
an
institution or in a
particularly satisfactory family environment, because of the

great weakness of will displayed by the patients. Later in
the course of the disease,
it
may
be necessary to employ
massage, and gymnastic movements in order to

combat the muscular atrophy accompanying the neuritis.
Some improvement of the memory disturbance may result
from systematic mental exercises.
electricity,

l
This psychosis is characterized by the sudden development of coherent delusions of persecution, based mostly upon
hallucinations of hearing, with barely
sciousness.
Etiology.
The
any clouding
of con-
etiology of acute alcoholic hallucinosis
is
Why
one
identical to that in delirium tremens (see p. 172).
case should develop into delirium tremens and another into
yet unknown. The various
explanations offered for this by Bonhoeffer and others are
acute alcoholic hallucinosis
Mitchell,
p. 251.
Types
is
of Alcoholic Insanity.
Amer. Jour,
of Ins. Oct. 1904,
190
Acute alcoholic hallucinosis represents, in
not satisfactory.
America, forty-five per cent, of the cases of alcoholic insanity

committed to institutions, and occurs mostly in men of middle
life,
many
of
whom
have been habitual daily drinkers for
years.
Symptomatology.
Occasionally, there are a few prodromal systems, such as indisposition, headache, dizziness,
insomnia, and irritability. The onset is usually sudden.
The patients at first are disturbed during the evening or at
night by indefinite noises, like shouting voices, cryings, and
ringing
These
bells.
hallucinations
soon
become more
when they hear their own names called and numerous epithets. The patients then hear remarks about themselves, which appear to come from the next room or from
definite
These remarks are usually quite
fellow-workmen.
clear,
and occasionally are heard in only one ear. The voices are
recognized as those of an acquaintance, a chum, or a fellowworkman, but rarely as those of the immediate family, and
consist of imprecations and references to misdeeds of their
They hear themselves called murderers, liars,

and thieves. They learn that they are to be electrocuted,
past
lives.
that the wife
is
unfaithful, or that the children have been
drowned. They are laughed

At times they overhear long
welfare, in
at because of their anxiety.

discussions concerning their
which various events
of their past lives are re-
hearsed or an indictment for murder
is
read against them.
men under their window discuss means of

them
and
capturing
bringing them to a public place for the
purpose of having them lynched. All this is so very real to
the patients that it is impossible to convince them to the
Again, a group of
contrary.
Furthermore, it almost always happens that the
voices are not spoken directly at them, but they only overhear what is being said among others about them. The
191
is always of a depreciatory
Besides these numerous hallucinations of hearing,
content of these hallucinations

nature.
there are a few hallucinations of sight, especially at night.

Strange and threatening forms appear before them, some
crawling from under the bed, others creeping on the wall;

brilliant specks come across the field of vision, and they may
even see double. At times the food has a peculiar taste,
and
excites suspicion.
In connection with these various hallucinations there

regularly develop pronounced delusions, mostly of a depresThe patients believe that they are the center
sive nature.
of attraction; every one about
them watches and threatens
Their every thought and action is known and commented upon. Passers on the street jeer at them, fellow-
them.
passengers on the trolley watch them closely, visitors in the

factory are told all about them and stand and gaze at them,
enemies shoot through the fence at them, and detectives

in citizen's clothes follow them wherever they go.
They are
on the alert
for impending arrest, or they go into hiding, and refuse to
leave their homes. These patients argue that they are condemned to die, and show considerable emotion. Fellowdistrustful of their surroundings, are constantly
patients refuse to speak to them because they are implicated

in the seduction of their wives.
Sometimes they refuse to
answer questions or associate with any one until brought to

the court
room
for the
supposed
trial.
At times they
find
consolation in prayer and in reading the Bible. These

various delusions usually remain within the realm of possibility, and appear more like attempts on the part of the
patient to explain the hallucinations. Occasionally, however, the delusions are of a fantastic nature and simulate
those occurring in delirium tremens, sometimes also being

associated with expansive delusions.
192
The
consciousness is barely disturbed, there being only a

dazedness.
Yet at night, and at the onset, there
slight
may be a slight transitory delirium. The patients are mostly
oriented, their speech coherent,
an accurate statement
of their
and they are able
to
make
symptoms, except occasionally
in giving the correct time of their occurrence.
They rarely
possess clear insight, but they often realize that they are
different, and frequently accuse their persecutors of drugging
them
or
"
only
making them
crazy.
Others claim that they are
nervous."
The emotional
attitude at the
onset
is
usually that of
anxiety, but later in the course of the disease there is that

characteristic mixture of anxiety and cheerfulness seen in
delirium tremens,
when
the patients relate their frightful
experiences with indifference, or perhaps laugh at the absurdity of their attracting so much attention. When not
in fear, they are quiet, reserved,
are monosyllabic.
In conduct the patients
infrequently continue at
But even during
and
may remain
work
quite orderly,
and not
and even weeks.

manner develop
They become reserved,
for days
this period peculiarities of
as the result of their delusions.

silent,
in replying to questions
and avoid acquaintances;
later they often apply to the
police for protection or hide under the bed, and some even
attempt suicide. In our experience these patients are some-
times the most dangerous of the insane. They take the law
own hands, purchase firearms, and assault those
into their
maligning their character or planning their destruction.
The sleep is regularly disturbed. The

appetite fails and there is a loss of weight. The reflexes are
occasionally exaggerated, and tremor of the tongue and hands
Physically.
is
often present, though not always.
neuritic
symptoms.
Occasionally, there are

The course
Course.
of the psychosis
may
193
be either acute
When acute, the duration varies from two to

three weeks, with rapid disappearance of the symptoms,
sometimes during a night. The prospect for a short course
or subacute.
seems better the nearer the symptoms approach those of

Occasionally, abortive forms of acute
alcoholic hallucinosis are observed, in which the patients for
delirium tremens.
a few hours or a couple of days suddenly develop isolated

transitory hallucinations, with anxiety, and a few persecutory
delusions, such as, that they are to be poisoned, assaulted
by fellow-workmen, or are watched by the police. In the

subacute form the symptoms may persist from one to eight
months, with numerous fluctuations, and then disappear
gradually.
The memory
for
events of the psychosis
is
usually excellent.
Diagnosis.
and acute
fined.
is
The
differentiation
alcoholic hallucinosis
is
between delirium tremens

by no means sharply de-
There are cases of the latter in which the orientation
markedly disturbed
for only a short time, hallucinations
of hearing are very pronounced,
and there seems
to be a
definite delusional connection between the various individual

morbid experiences, while, on the other hand, the difficulty
of apprehension, the disturbance of the impressibility of
memory, the presence
suggestibility, restlessness,
delirium tremens.
and tactile hallucinations,

and tremor give the stamp of
of visual
Provided they are not simply cases of
undeveloped delirium tremens, may they not possibly represent a combination of delirium tremens and acute alcoholic
hallucinosis, similar to those cases of delirium
tremens occa-
sionally seen in epileptics, paretics, hebephrenics, and
But usually the retention of a good

of restlessness and striking physical
of hallucinations of hearing
manics ?
orientation, the absence

signs, the predominance
with coherent delusions based
194
upon them, and a more prolonged course are
sufficiently
distinctive evidences of acute alcoholic hallucinosis.
The
differentiation
from dementia
particularly
prcecox,
the paranoid form, may be difficult, but in dementia prsecox

the onset is far more gradual: there is stupidity; looseness
of thought; a lack of energy for work; peculiar conduct,
such as, staring, impulsive acts, and catatonic signs. The
in dementia prsecox are directed to the
in
while
the alcoholic psychosis the patient simply
patient,
overhears what is said. The delusions involve mostly the
hallucinations
physical
and mental
personality,
which in the alcoholic
psychosis are not involved. Finally, the emotional attitude

is superficial, while in the acute alcoholic hallucinosis the
is genuine and often desperate, except for the occasional appearance of the alcoholic humor.
Paresis may be
anxiety
differentiated
by the same signs in addition to the presence

and weakness of memory and judg-
of paretic physical signs
ment.
some
Some
cases of manic-depressive insanity
may
similarities to acute alcoholic hallucinosis,
present
but they
can be successfully differentiated by the previous history

of the case,
and by tendency
to delusions of self-accusations,
which are absent in the alcoholic condition.
The outcome
usually favorable, as a large

proportion of the acute cases recover. There is great danger
of relapse with continued drinking, and subsequent attacks
Prognosis.
is
more prolonged. Some patients have four or five attacks.

The outlook in the subacute cases is not as favorable, as less
than twenty-five per cent, wholly recover. In some cases
are
there finally develops a condition of permanent dementia,

with hallucinations and delusions.
Treatment.
The
chief indications are the absolute with-
drawal of alcohol, the administration of a nutritious
and incessant watching to prevent injury
to self
and
diet,
others.
ALCOHOLIC HALLUCINATORY DEMENTIA
The course
of the disease
may sometimes
195
be cut short at the
onset by the use of hypnotics to overcome the insomnia and

of the prolonged warm bath to ameliorate the anxiety.
ALCOHOLIC HALLUCINATORY DEMENTIA

This type of alcoholic psychosis, provisionally called alco1
hallucinatory dementia (or alcoholic paranoia ), is
holic
characterized
lucinations,
fluence
and
by the sudden development
numerous
hal-
many depreciatory delusions of reference,

persecution, associated somatic delusions,
in-
of
and
occasional change of personality, with some emotional anxiety

and irritability, usually leading after a long course to moderate
dementia.
It frequently represents the
end stage
of the
acute alcoholic hallucinosis and as often follows delirium

tremens.
Symptomatology.
The onset
coholic hallucinosis or delirium
is
sudden.
If
acute
al-
tremens have
preceded,
the patients having become oriented and quiet, and having
corrected at least a part of their delirious experiences, continue somewhat constrained and suspicious. Then hallucinations, particularly of hearing, develop again,
and the
of hearing threatening voices, that others
patients complain
are reading their thoughts, and that they are being influenced
in various ways.
They feel that they are being hypnotized,
chloroformed, are experimented upon when

think
that men are breathing on them, smearing
asleep;
mucus over them, changing their clothing, and creating diselectrified, or
gusting odors about them.
Comments
are printed in the

actors make allusions
daily papers about themselves, and

to them from the stage.
Very often their delusions have a
when they claim that they have been ashave

their
semen drawn off nightly, and that their
saulted,
sexual content,
Luther, Allgem. Zeitschi fur Psychiatric, LIX, 20, 1902.
196
organs are being shrunken up. These delusions are usually

not elaborated, but remain unchanged from week to week,
and are almost always expressed in the same phraseology.
Witches and
spirits are
everywhere, assuming various forms,
offering threats; everything is poisoned, and

cannot
escape the hypnotic influence. Occasionally,
they
the delusions are still more fantastic and quite changeable.
Expansive delusions may appear, but they also are limited
and constantly
The patients' judgment concerning the surroundings, except in the severer
in content, although they are fantastic.
cases, is quite
good; they exhibit activity, converse with

show a tendency to
their associates, follow a daily routine,
employ themselves, and are quite natural,

delusions are not involved.
in as far as their
The memory shows no
striking
Nevertheless, one can detect a considerable
disturbances.
degree of mental weakness.

The emotional attitude at the onset
is one of anxiety or
at
times to attempt
the
patients
irritability, impelling
suicide or attack their persecutors.
Later, there regularly
develops a more or less humorous attitude, manifested in

witty and facetious remarks and rendering the suspicious
patients more pliable and approachable.
Physically, besides the alcoholic tremor, there are often
present more or less severe neuritic disturbances.
and
excitable
The course
Course.
enforced,
is
of this disease, unless abstinence
With
progressive.
and delusions slowly subside.
hallucinations
is
persistent abstinence, the
In some cases
entirely vanish, leaving the patient in a condition

But usually they persist for
of simple alcoholic dementia.
they
may
many
years,
though steadily becoming weaker.
ous fluctuations of the
symptoms
Numer-
are characteristic; at times
the patients express some insight into their condition; they

think that they are sick, but they have no idea of how they
ALCOHOLIC PARANOIA
came
into such a state,
197
and they are able
also to associate
manner with their supposed persecutors; at

other times they become excitable without apparent cause,
in a friendly
complain of threatening hallucinations, and also become

aggressive, but they are usually quieted without difficulty.
Alcoholic hallucinatory dementia
Diagnosis.
may
be
distinguished from some of the end stages of dementia prcecox

by the history of the development of the disease, by the fact
that the patients possess a greater emotional and intellectual
activity, are
show the
more natural and approachable
characteristic alcoholic
symptoms do not progress
if
humor.
in conduct,
and
Furthermore, the
total abstinence is maintained,
but rather tend to subside. There is, occasionally, a case of

severe alcoholism, with pronounced catatonic symptoms.
In such cases it would seem justifiable to assume that there
is
a combination of both diseases.
ALCOHOLIC PARANOIA
This form of alcoholic insanity comprises a small group of
who gradually develop a delusional state
chronic alcoholics
characterized particularly by delusions of jealousy.
Symptomatology.
The family
discord
that
naturally
follows excessive drinking, together with the wife's aversion
to sexual intercourse, and the increasing impotency of the
alcoholic, is the nucleus about which the delusions of
The tendency displayed by the alcoholic to

jealousy form.
lay the blame for everything upon some one else, naturally
engenders the idea that the wife is unfaithful, and that the
real cause of these difficulties lies in the fondness of the
wife for other
men
or of the
men
for other
women.
Insignificant occurrences are regarded as important evidence of

this infidelity: the assistance of some one in carrying a
bundle, the fondness of a friend for their children, the
198
voluntary implication of a neighbor in a family quarrel.

The frequent clanging of a car bell means that the motorman is a correspondent. A side glance from a passer on the
street, the arrival of
an unusual
letter,
with another man's wife are held as
and even association
sufficient proof of the
suspected misbehavior. Furthermore, the home and children are neglected.

Patients have seen the wife enter the
apartments of a neighbor, and from noises which they have

heard are sure that she was guilty of adultery. Frequently,
the children are disclaimed as those of other men, and hence
must share in the abuse. Sufficient evidence of this is found
in the fact that they have different colored hair or different
The saloon keeper is implicated, if he refuses

dispositions.
to give them credit for liquor, or the coachman, if he hapAssociated with
pens to be amiss in any of his duties.
these delusions of infidelity there
may be
delusions of poi-
soning.
These delusions of jealousy are by no means confined to

married persons, but also exist in the unmarried when those
persons with
mother,
whom
sister,
they are most intimately associated, the

the paramour, and sometimes the clergy
become the objects
of their jealousy
and
assaults.
These
and usually remain within

the realm of possibility. The patients, however, state them
coherently, oftentimes displaying considerable emotion, and,
indeed, in this way they frequently convince chance acdelusions are not elaborated
quaintances of the great injustice done.
There are occa-
hallucinations of hearing, when the patients hear

peculiar noises about the house, such as a creaking of the
sional
door,
whispering, rattling of the shutters,
or suspicious
sounds in another room. There may be a peculiar odor in

the house, or an odd taste in the food, which is offered as
proof that an effort is being made to poison them. This
ALCOHOLIC PARANOIA
incites
them
to nail
down
199
the windows and to fasten the
door in order to keep out the lovers.

There is no clouding of consciousness.
In actions, the
patients usually exhibit marked weakness; they bemoan

their misfortunes while submitting to the injustice.
At
times the actions are entirely out of accord with their delusions,
and
this is especially true in cases of long duration.
A man may live peaceably with his wife, whom he accuses of

Sometimes they are
may be both aggressive
committing adultery night after night.

very
and
irritable,
and
in fits of anger
When under
destructive.
conduct of the patients
is
the influence of alcohol, the
apt to be wholly changed; then
they become aggressive and threatening and, not infrequently,

make murderous assaults upon their wives or the objects of
their jealousy.
Course.
The
course of the disease
is
usually progressive.
delusions seldom disappear permanently, though abstinence from alcohol often brings improvement, especially in
The
conjunction with confinement in an institution. When removed from home environment, the delusions subside and
In some patients
patients are able to live very comfortably.
the delusions subside and are denied; they desire to " let
"
bygones be bygones ";
everything is past," and allow the
inference that they have been mistaken.
improvement, oftentimes accompanied by
sight, influences
This apparent
an alleged
one to yield to their importunities for
inre-
lease; but regularly the return to home surroundings, with

an opportunity to secure alcohol, soon leads to recurrence
of delusions.
Diagnosis.
It is often difficult to distinguish the delu-
sions of infidelity expressed
occurrences and facts.
quently results in
by the patient from actual
The conduct
of the alcoholic fre-
an actual and permanent estrangement
of
200
the
man and
adultery.
wife,
One must
for jealousy offered
which naturally smooths the way for

rely in his judgment upon the grounds
by the
which the patient draws
patient.
The
his conclusions
positiveness with
from
insignificant
and the conviction with which he applies these to

others, and finally the occasional relation of strange condata,
doubt as to the delusional origin

Indeed, under some circumstances
we can come to the conclusion that a jealousy which appears
to be justified by real circumstances, nevertheless, on account
clusions should leave little
of the ideas of jealousy.
of its peculiar basis, must be regarded as morbid. This is

especially clear when we observe how the patient disregards,
with unconcern, the
real, open adultery of the wife, while

the delusion leads to passionate outbreaks. Delusions of
infidelity may occur in the psychoses of the period of involution and occasionally also in dementia prsecox. In
general, the delusions are less apt to be fantastic in the alco-
and there are lacking the physical sensations,

the hallucinations, and the nocturnal experiences which are
holic psychosis,
encountered in the other psychoses. In addition to this,

there is a striking contrast between the subsidence of the
symptoms, the weakness of will shown by the alcoholic upon

enforced abstinence, and his brutality and animosity when
unrestrained. This psychosis is differentiated from paranoia
by the lack of a stable systemization of the delusions and by

the symptoms of chronic alcoholism.
Treatment.
In these cases the treatment
is
confined to
enforced abstinence and careful watching or confinement in
an
institution to prevent assaults.
ALCOHOLIC PARESIS
This psychosis represents in the majority of cases a simple
combination of the symptoms of chronic alcoholism with
ALCOHOLIC PSEUDOPARESIS
those of paresis.
There*
is
201
added to the defective memory
the expansive delusions and the emotional deterioration of

paresis, the hallucinations and delusions of infidelity of the
alcoholic; while the speech disorder of the paretic
is
accom-
panied by the tremor and neuritic disturbances of the alcoholic.

Epileptiform attacks also are particularly numerous.
Usually the signs of alcoholism have existed for some time
before the paretic symptoms develop. On the other hand,
the
initial
symptoms may lead to such

symptoms develop.
excessive drinking
that the alcoholic
ALCOHOL PSEUDOPARESIS
There are included here severe cases of alcoholic hallucinatory dementia with more or less pronounced signs of
Korssakow's psychosis, in which physical symptoms predominate,
as,
tremor, speech disorder, ataxia, paralyses,
These cases are disrigid pupils, and paralytic attacks.

tinguished from true paresis by the history of their development, the predominance of the polyneuritic symptoms, the
active hallucinations, and the more prolonged course, which
leads to a simple alcoholic dementia and not to the absolute
dementia and death that characterizes paresis.
MORPHINISM
B.
THE
extensive use
effects place it
and abuse
of
morphin
for its alluring
second only to alcohol in the production of
mental and physical wrecks.
The
intolerance of pain among people of this

age, together with the laxity of the physicians in disEtiology.
pensing analgesics, accounts in part for the extensive use

of this drug.
Being an expensive drug, its victims are
limited to the better classes.
the patients are those
who
Considerably over one-half of

are best acquainted with its ill
At
physicians, dentists, and professional nurses.
least one-half of these patients are men.
On the Continent
effects
claimed that seventy-five per cent, are men.

An important etiological factor is the defective constitu-
it is
tional basis, evidences of
which in very many cases are
manifested by various neuroses, as hysteria.

free
from
this hereditary taint usually
earlier
Individuals
succumb to the drug
after its continued
employment in persistent painful affecas

tions,
neuralgia, sciatica, rheumatism, headache, dysmenorrhcea, and different forms of colic. The pleasurable
feeling and the mental stimulus which supplement the
analgesic effects are here the cause of its continuance. The
majority of cases develop between the ages of twenty-five

to forty years.
In animals to which morphin

had been administered for a prolonged period, Nissl has
demonstrated a shrinkage of cortical neurones with an

increase of the neuroglia.
202
MORPHINISM
203
Acute Morphin Intoxication.
Symptomatology.
The
physiological action of morphin is to first produce an

acceleration and excitation of the process of comprehen-
sion
and a psychomotor retardation, which
later passes into
a befogged state, with changing fantastic hallucinations and
an intense weariness
in the
psychomotor functions.
Then
ensues a quiet, pleasurable feeling, which acts as one of the

strongest enticements for the habitue. For him it also pro-
duces a necessary stimulus for mental work, which cannot

be accomplished by the exercise of the will power alone.
There develops a metallic taste in the mouth, and sometimes

rumbling in the bowels. Fortunately the drug fails to produce these pleasurable effects for all, owing to idiosyncrasies.
Many
after its exhibition suffer
from a disagreeable fulness

nausea, and
general feeling of discomfort,
in the head,
Following the intoxication there is apt to

be headache, profuse perspiration, and diminution in all of
colicky pains.
the secretions of the body.

Chronic Morphin Intoxication.
In the prolonged use of

acute
intoxication
disappear, and the
morphin
individual obtains only the exhilarating and the quieting
the effects of
effects,,
his
which aid in endurance of annoyance incident to
work or
his
home
life.
The
beneficial effects of this
drug diminish with usage, and soon necessitate increased

dosage, which may, in time, reach from thirty to fifty grains
The frequency
must also be increased.

The character of the symptoms and the time of their appearance depend mostly upon the individual constitution
and its powers of resistance. Some continue addicted to
daily.
of the doses
morphin throughout life without pronounced ill effect; others

succumb in the course of a few months. In these the memory
weakens, and the capacity for mental application diminishes.
Difficult and exhausting work becomes impossible without
204
administration.
Consequently the patients are either in

a condition of exhilaration, stupidity, or nervous irritability,
its
none
of
which are compatible with mental work.
Emotionally, these patients exhibit many variations they

are sometimes dejected, irritable, cross, hypochondriacal;
:
sometimes confidential, over-nice, with pronounced affecta-
and occasionally anxious,

there is a pronounced change
especially at night. Morally,

of character, noticeable es-
tion;
reference
pecially
in
willingly
submit to
to
their
all sorts of
habit.
irresistible
They
depraved means in order to
secure the drug. Finally all idea of personal responsibility

vanishes. The home and the business suffer alike, and they
fall
into a state of apathy
and
an absence of
about the dress
indolence, with
power and energy. They are careless

and the personal appearance. In actions they are apt to
be sleepy during the day, and active and restless at night,
reading, busying themselves about foolish trifles, and talk-
will
ing incessantly. They are also disagreeable, faultfinding,

to the extreme.
Very many of them become
and obstinate
addicted to alcohol, and other drug habits.

The patients lie
Physically, the sleep is much disturbed.
awake for hours, their minds busied with all sorts of fantastic ideas,
sometimes accompanied by genuine hallucina-
tions of sight.
Disturbances of sensibility are usually present, such as parsesthesias and hypersesthesias, especially
about the heart, the intestines, and the bladder. There is

usually an increase of the tendon reflexes. The movements
are uncertain,
sionally there
tremulous,
is
and sometimes
difficulty in speech,
ataxic.
Occa-
also paresis of eye
muscles (double vision and defective accommodation). The

general nutrition suffers, and there is loss of weight. The
skin is flabby and dry, due in part to the absence of normal
secretions.
The
appetite, especially for meat,
fails,
though
MORPHINISM
sometimes there
mouth
there
is
is
205
a ravenous appetite. Dryness of the

In the circulatory system
creates unusual thirst.
noticed palpitation, and slow, irregular pulse. The

numbness, vertigo, and syncope, as well
ringing in the ears,
as the profuse perspiration

to vasomotor disturbances.
and shivering, are attributable

The lack of sexual desires and
impotence are prominent symptoms; in women there is

amenorrhcea and sterility. The ensemble of these symptoms
creates the picture of premature senility.
Abstinence Symptoms.
The abrupt withdrawal of morin
individuals
who
are
addicted
to large doses produces
phin
in the course of a
toms
few hours a characteristic train of symp-
abstinence symptoms. These, according to

Marme, are due to the action of oxydimorphin. The withdrawal even in milder cases is always attended with more
called
less disturbance.
The patients become tremulous
and uneasy, experience a tickling sensation in the nose and
or
begin to sneeze;
feel oppressed,
different parts of the body,
complain of paraesthesias of
and are
sleepless.
The adminis-
tration of hypnotics, especially chloral, at this time, only

increases the excitement and aids in bringing about a
delirious condition with hallucinations
and dreamy confu-
In spite of precaution, however, a condition very

similar to delirium tremens may appear.
This condition
sion.
but a few hours, or at most a few days. Occasionally

there appears a condition of dazedness, with hallucinations
lasts
and convulsive movements.
Physically, the patients display

twitchings of the limbs, spasm of
involuntary movements,
the diaphragm, paresis of the muscles of accommodation,
tenesmus, paleness and flushing, vomiting, palpitation of the
heart, fainting and collapse with heart failure, which is

sometimes fatal. The secretion of saliva and perspiration,
which during the ingestion of morphin has been diminished,
206
now becomes excessive, and there is colliquative diarrhoea.

Albumen is usually present in the urine. The duration and
symptoms depend upon the constitution of
the patient, the duration of the habit, and the size of the
habitual dose. The symptoms disappear gradually, except
intensity of the
where they may vanish rapidly after a

In
the course of a few days, perhaps weeks,
prolonged sleep.
the patients begin to sleep and develop an appetite, but
in the lighter cases,
from
this point convalescence progresses very slowly.
The rapidity with which the symptoms of

Course.
chronic morphinism develop varies with the power of resistance of the individual and the quantity of morphin
ingested; in some cases it requires a few months, in others
The duration also varies; some die within
several years.
a year of inanition, heart

live for
many years
The
failure, or in collapse,
in spite of large
while others
and increasing
doses.
Diagnosis.
may be recognized by the varying emotional attitude; periods of mental -freshness and unusual energy with a feeling of well-being, alternating with
disease
great weariness, stupidity, dejection, and irritability, and

furthermore by the physical signs the loss of sexual power,
:
anorexia, myosis, and general muscular weakness, amounting in some cases almost to paresis. Scars from the hypo-
dermic injections should always be looked
means
of diagnosis
is
for.
The
surest
seclusion or close surveillance for a
week, during which time the demand for the drug or some
abstinence symptoms will appear.
Prognosis.
The prognosis
is
always very serious.
Less
than ten per cent, recover permanently; relapses are the

A few cases die from overdoses of the drug. The
greater danger lies in cardiac weakness, which may lead to
sudden collapse and fatal termination. The drug may be
withdrawn with the proper precautions and the patients
rule.
MORPHINISM
207
no ill-effects. Often, when the patients do not reinto

lapse
morphinism, they revert to substitutes, of which
the most important are cocain, alcohol, chloroform, ether,
suffer
and
chloral.
The treatment
preeminently unsuccessful in
is
those with strong neuropathic tendencies.

The only successful method of treatment
Treatment.
complete abstinence.
For
this
is
purpose the first requisite is

This method of treat-
isolation in a reputable institution.
ment, however, cannot be safely undertaken in all cases,

and especially where conditions of physical weakness are
present, also during pregnancy, acute and severe chronic
There are two methods of withdrawal, the
diseases.
gradual and the rapid, the latter of which requires the

greatest skill and is by far the most efficacious. The former
involves
much time and patience, and is apt
and disagreeable
traits
which
eradicate as the habit
itself.
to create chronic
end are as difficult to

For these reasons only the
in the
rapid method is outlined here. It is necessary that the

patients be placed in bed. In mild cases the drug may be
withdrawn abruptly. Even in these the abstinence symptoms may appear. In cases where the dose has been large,
the quantity is immediately reduced one-half, and after
twenty-four hours to a nominal dose of one grain daily for
several days, and in the course of two weeks entirely withdrawn.
During the period of withdrawal the drug
is
best
given in single daily doses in the early evening. If previously taken hypodermically, the drug should at once be
changed to administration by mouth. Abstinence symptoms occur within the first thirty-six to forty-eight hours
after the withdrawal of the drug
and demand
careful watch-
ing on the part of the physician. To guard against these

and to add to the comfort of the patient, alcohol in small
doses with light nutritious diet may be given. Where there
208
impending collapse, faradization of the skin, injections of

ether or camphor, the administration of hot coffee or hypodermic injections of strophanthus and strychnia are indiIf these fail,
cated, the last of which is often essential.
immediate
relief
in
finds
return
to
the
one always
usual dose
is
The greatest restlessness and insomnia often

of ice packs on the head.
influence
If unto
the
yield
The local
successful, the various hypnotics may be tried.
of morphin.
also be relieved
pains
may
tion
should be
applied
by the application
early;
this,
of ice.
however,
is
Purgacontra-
by pregnancy or an acute, serious, or chronic

Diarrhoea demands no special attention. Finally,
disease.
it requires many months, and in some cases a year, to reestablish the former mental and physical health so that
indicated
they are able to return to their old associations without

fear of relapse.
Even
after being fully reestablished in
health,
necessary from time to time that the patients
be subjected to close surveillance to ascertain if there is a
it is
return to the old habit.
C.
COCAINISM
COCAIN, in distinction from alcohol and morphin in its

effects, is characterized by the great rapidity with which it
produces profound mental enfeeblement and physical inaniIt is of rare occurrence to encounter symptoms of
tion.
cocainism alone, because of the frequency of its complicaFor this reason it is
tion with alcoholism and morphinism.
draw a pure clinical picture of the disease.

The conditions giving rise to cocainism are
Etiology.
similar to those encountered in morphinism.
Most of the
a
have
and
strong neuropathic basis,
patients
many of them
difficult to
have previously been addicted to morphin. Early in the

history of cocainism the habit arose from the substitution
in the treatment of the latter habit,
but at the present time most of the patients are physicians
of cocain for
or druggists.
morphin
The usual method
of administration is
by the
syringe, although
may be taken by insufflation.
Acute Cocain Intoxication.
Cocain in
Symptomatology.
small doses produces moderate mental excitement, with a
it
and
warmth and
well-being, increase of pulse rate,

a fall of blood pressure. Its effects in the psychomotor
feeling of
field are similar to
those of acute alcoholic intoxication: an
The patient is active,

and
is talkative.
This
to
write,
impelled
sooner or later followed by drowsiness.
Large
excitement followed by paralysis.

energetic,
condition
feels
is
doses lead to delirious states with a tendency to collapse.

Nissl has found in experiments upon rabbits that in the
210
but a very slight alteration in

a moderate disintegration of the
chromophilic granules, some staining of the achromatic
substance, and a moderate increase of the glia cells.
acute intoxication there
the cortical neurones;
is
i.e.
Chronic Cocain Intoxication.
In one accustomed to the
prolonged use of the drug, there is a continuous mental state

of nervous excitement with a flight of ideas, complete incapacity for mental work, lack of will-power, and defective
memory. The patients are overenergetic, but their activity
and very productive, writing

lengthy, meaningless letters, and evolving on paper impracticable schemes.
They neglect their professional and home
is
planless; they are talkative
In emotional
duties, also their personal appearance.
tude there
nounced
anxiety.
is
atti-
a variation between exhilaration with a proof well-being and great irritability and
are very apt at times to mistrust their surthe same time they exhibit more or less in-
feeling
They
At
roundings.
difference as to the legal consequence of their acts.
memory becomes
defective
The
and the judgment much im-
paired.
Physically, the
most prominent symptom
is
the profound
disturbance of nutrition; the patients lose weight very

rapidly, the normal expression changes, they look sleepy
and tired, the skin becomes flaccid and pale. This is due
in part to the fact that the drug supplies the place of nutritious food, for which they have lost all desire, and in part
excessive glandular action which

drain upon the body tissues. There
to
and increased myotatic
The
muscular twitchings.
normally, and there
irritability,
is
makes a continuous
is
muscular weakness
noted sometimes in the
pupils are dilated,
tremor of the tongue.
but react
In the
cir-
culatory system there is slowness of the pulse, palpitation,

to faintness.
In spite of increased sexual
and a tendency
COCAINISM
211
excitement, the sexual power diminishes.

turbed,
and occasionally interrupted by
The
sleep
is dis-
hallucinations.
the basis of chronic cocainism there
may develop
Upon
a definite psychosis which bears close resemblance to the
acute alcoholic hallucinosis.
Following a few days of
with anxiety and some restlessness, there appear
Acute Cocain Hallucinosis.

irritability
suddenly hallucinations of different senses; the patients

hear threatening voices compelling them to act strangely,
and see moving pictures on the wall, which are filled with
large
and small
objects.
Characteristic of the hallucina-
minute black specks moving about on a light

are mistaken for flies, mosquitoes, and other
which
surface,
tiny objects. This, according to Erlenmeyer, is an evidence
tions are the
of multiple disseminated scotoma.
Peculiar sensations in
they are being worked upon

by electricity, being thrust with needles, or that poisonous
material is being thrown upon them; but most characteristic
the skin create the belief that
the sensation that foreign objects are under the skin,

especially at the ends of the fingers and in the palms of the
is
The muscular
hands.
twitchings, they believe, are due to

The hallucinations of hearing
the action of some poison.
make them suspicious of their surroundings.

are being read by
means of some
Their thoughts
secret contrivance; they are
being spied through holes in the ceiling. Some patients become so thoroughly frightened that they attempt to kill
their
supposed persecutors,
or
in
despair
may commit
suicide.
A characteristic symptom is the silly delusions of infidelity.

Wives or
These are frequently obscene in character.
of
husbands are accused of illicit relations,
receiving many
love letters, of stealthily leaving the house and neglecting
the family for immoral purposes, or of becoming
known
as
212
public characters.
usually vindictive
In reaction to these ideas patients are
and may even become
The consciousness remains

tion, except in rare instances
aggressive.
There
is good orientawhere the excitement is very
clear.
great, or immediately following fresh injections of the drug.
In emotional attitude patients are always dejected, excitable,

irritable, and sometimes passionate.
Occasionally they are
reserved
and
reticent concerning their delusions.
In actions
they are usually very restless and unstable, though some may
appear quite orderly. In the markedly delirious conditions
which sometimes appear there is always great restlessness.

Acute cocain hallucinosis develops rapidly and may run
its full course within a few weeks.
The symptoms increase
under
the
of
influence
The
rapidly
single doses of cocain.
delirious state soon disappears after the complete with-
drawal of the drug, sometimes within a few days, while the

delusions may remain for weeks or even months. The co-
morphinism and cocainism in the same individual, which is of common occurrence, frequently leads to
a combination of the symptoms. Morphinism alone seldom
produces a rapid development of pronounced mental disexistence of
turbance, unless in connection with cocainism.

Acute cocain hallucinosis is differentiated from acute
by its more rapid development, the

symptoms, and by the fact that the
jealousy appear earlier and as an acute symp-
alcoholic hallucinosis
greater severity of the

delusions of
The
a single dose of cocain during the psychosis produces an exacerbation of the symptoms, while in
alcoholism it has little or no effect. Finally, the sensation
tom.
of objects
effect of
under the skin
is
characteristic only of cocainism.
The prognosis in cocainism is unfavorable for complete

recovery. The symptoms of intoxication clear up after the
withdrawal of the drug, but the power of resistance
is
pro-
COCAINISM
213
foundly affected, and few resist temptation for any great

length of time.
Treatment.
The only
complete abstinence.
drawal, similar to that
is
successful method
The rapid method
of treatment
of the with-
in morphinism, is best.
attended
only by unimportant
usually
symptoms, such as uneasiness, a feeling of pressure in the
chest, with difficulty in breathing, also palpitation of the
The withdrawal
heart,
employed
is
and insomnia, and occasionally by a tendency to
faintness which
it is
simulates collapse. If such emergency arises,

necessary to employ stimulants, as alcohol, camphor,
The insomnia may be combated with

prolonged warm baths, paraldehyde trional, and also by a
coffee, strychnia, etc.
nutritious diet.
An
essential element in successful treat-
ment is confinement in an institution, where it can be

mined with certainty that the patient does not have
to the drug.
deter-
access
Prolonged treatment with the employment of
him against relapses is an

which
requires patience on the part of the
important factor,
patient and perseverance and tact on the part of the phy-
every possible means to fortify
morphinism and cocainism

be withdrawn first.
sician.
If
coexist, cocain should
THYROIGENOUS PSYCHOSES
IV.
THE two
forms of psychosis arising from disturbance of
the thyroid gland are myxcedematous insanity and cretinism.

They develop directly as the result of an absence of glanducretinism appearing in early childhood, and
myxcedematous insanity in adolescence and later. Rightlar activity,
fully the
symptoms accompanying Graves's
this group,
disease belong in
but are not described because of their com-
paratively infrequent occurrence.
A. MYXCEDEMATOUS INSANITY
The mental disturbance
characteristic of
myxcedema
is
that of a simple progressive mental deterioration accompanied by the characteristic physical symptoms of the
disease.
The lack of glandular activity in the thyroid

to
be the exciting cause by failing to neutralize
supposed
or care for some toxic product of metabolism. The gland
Etiology.
is
in all cases
is
found atrophied or diseased.
This
is
fre-
quently the result of connective tissue increase, sometimes

of colloid degeneration,
and
rarely of tuberculosis or syphilis
of the gland.
is
The onset of the mental disturbance

Symptomatology.
with
gradual,
increasing difficulty of apprehension. The
patients do not comprehend written or spoken language as

well as formerly, and are unable to collect their thoughts.
It takes
them
longer to perform ordinary duties, such as

214
215
Memory for recent events

dressing, and they also tire easily.
becomes defective. The increasing difficulty in applying the
mind and in performing even simple acts finally renders
them completely helpless.
sciousness.
At first they
no clouding of conexhibit some insight into their

but
this
later
defects,
gives way to indifference and stupidity,
not only in reference to themselves and their condition, but
There
is
also to their environment.
pain,
They rarely express pleasure or

and very seldom give evidence of thought for them-
selves or their future.

tic for
them
In emotional attitude
to be anxious, dejected,
Sometimes they develop
ment with stubbornness.
restlessness
In rare cases there
conditions of confusion with hallucinations

Physically,
it is
characteris-
and at times
and moderate
and
may
fearful-
excite-
appear
delusions.
they present characteristic cutaneous and
nervous symptoms.
The skin becomes
thick
and
dry,
rough, inelastic, obliterating the characteristic lines of expression in the face, producing thick lips, broad nose, and
The mucous membrane

is similarly involved, and the tongue is thick and unwieldy.
The cutaneous change is most marked in the supraclavicular region, in the upper arms, and in the abdominal wall.
The voice is changed, becoming rough and monotonous, and
the speech is slow and difficult. The nervous symptoms condeforming the hand and
fingers.
headache, vertigo, fainting, convulsive spells,

and a fine tremor. Finally the skin and mucous membrane
sist chiefly of
become anaemic and very sensitive to cold, menses cease,

and temperature becomes subnormal. The blood changes
vary; sometimes there is an increase of the red corpuscles,
and at other times a diminution.
Course.
The psychosis is of gradual onset, and unless
treatment
is applied, progresses to advanced
appropriate
deterioration, extreme physical weakness, and profound dis-
216
turbance of nutrition, the disease terminating fatally through

the intervention of some intercurrent disease. Occasionally
there are intermissions, and in a few cases marked improvement occurs in spite of the absence of treatment.
The administration of
beginning at one and one-half
Treatment.
sheep,
be regarded as a specific remedy in this

The dose is gradually increased, guarding carefully
times daily,
disease.
dried thyroids of the

grains, one to three
may
against intoxication symptoms, indicated by headache, dizziThe improvement beness, and irregular cardiac action.
comes evident within a week and increases very rapidly.

The patients become active and show an interest in themselves and surroundings; they improve in memory and in
judgment.
rapidity.
The physical symptoms improve with equal

In the most successful cases the patients appear
quite well at the end of

tude, which
persists for
through medication;
difficult to ascertain
two months, except for some lassia long time. Not all cases recover
the
number
at present.
of unsuccessful cases is
may
Relapses
occur.
B. CRETINISM
Cretinism
is
characterized
by a more or
less
high-grade
defective mental development, associated with loss of function of the thyroid,
and accompanied by
definite physical
symptoms.
Etiology.
ous regions.
The
disease
is
mostly endemic in mountain-
In Europe the cases are most numerous in
the Alps and Pyrenees; in America, in Vermont. Sporadic

cases occur as the result of congenital absence of the gland
or its atrophy during or following a fever, or in connection
with goitre. The disease arises from an organic infectious
material, and is in some way associated with disease of the
parathyroid gland.
It is
unknown whether
this infectious
217
the cause of an atrophy, a non-development, or

disease of these glands, in this way producing a failure of
organism
is
mental development;
or whether
due to the direct

toxin upon the nervous system.
it
is
action of the organism or its

Other important factors are defective neuropathic basis
and
unhygienic surroundings.
The morbid anatomy is still

doubtful. Asymmetries and dilatation of the ventricles of
the brain and atrophy have been found, also hyperostosis of
the cranium. The cortical neurones are deficient in num-
ber and processes, and are of the stunted globose form

peculiar to idiocy and other forms of defective development.
The symptoms of the disease are first
Symptomatology.
noticed during the first and second years, except in a few
cases where the children are born goitrous.
At that time
dull, stupid, indifferent, sleepy, and unable to
care for themselves; have not learned to walk or talk, and
they appear
and awkward in their movements. The gland inin size from the sixth to twelfth year in three-fourths
are slow
creases
of the cases; in the remaining
Mentally, the
to
the
patients
develop, presenting
symptoms of imare
of
dull, stupid, incapable
becility;^ they
apprehending or
it
diminishes.
fail
of elaborating impressions, presenting
a five-year-old child.
They
and quite incapable
matic,
about the capacity of
are rather indifferent
and phleg-
of applying themselves to
any
A few cases present a condition of extreme stupidity.
work.
Their condition remains unchanged throughout
life,
except
as interrupted by short periods of excitement, similar to

those occurring in idiocy. This condition may form a basis
for the
development of other psychoses, especially manic-
depressive insanity.
Physically, the long bones fail to develop in length, instead,
becoming thicker.
The head
is large,
and the neck
218
short
and
thick.
The nose
broad, and the ears are promithickened as if padded, and in places,

is
nent, the skin is

The
especially in the neck, hanging dependent in folds.
broad face, with heavy cheeks and eyelids, with thick lips
and broad short nose, presents a very characteristic picture.
and pudgy. The tongue is thick and

clumsy in its movements. The hair is scanty, and dentition
The speech consists of inarticuis late and the teeth poor.
late sounds, which are loud, coarse, slurring, and stammerThe movements are unwieldy, the gait slow and cuming.
bersome. Convulsions are rare. The sexual organs develop
slowly, and in severe cases remain entirely undeveloped.
The limbs
are large
Patients have
little
power
of resistance, readily
succumbing
to intercurrent diseases.
The hygienic surroundings must be imwith

proved
special attention to drinking water.
Many
observers agree that it is advisable as a prophylactic measure
Treatment.
to send children
and
families with cretinoid tendencies to
the high mountains, which may bring about a complete

recovery in children who already show some signs of disease.
Potassium iodide in small doses seems to be
beneficial.
According to recent observation the administration of desiccated thyroid, if given early, may aid in preventing the
development of the disease.
After an extended duration the
same drug may improve some of the physical symptoms,

thickness of the skin and amenorrhoea,
but the mental
symptoms cannot be
altered.
V.
DEMENTIA PR^COX
DEMENTIA PR^COX
is
the
name
provisionally applied to
a large group of cases which are characterized in common by

a pronounced tendency to mental deterioration of varying
grades. The disease apparently develops on the basis of
a severe disease process in the cerebral cortex, but whether
always the same is by no means certain.

Dementia fortunately does not occur in all cases, but it is
so prominent a feature that the name dementia prsecox is
the process
is
best retained until the
The
symptom group is better understood.
one of the most prominent,

comprising from fourteen to thirty per cent, of all admisEtiology.
disease
is
sions to insane institutions.
As the name
indicates,
it is
More than sixty per cent. of the

life.
cases appear before the twenty-fifth year. This, however,
varies in the different forms; in hebephrenia almost threea disease of early
Finzie Vedrani, Rivista sperim.de freniatria,
XXV,
1899; Chris-
Ann. me"dico-psychol. 8, 9, 43, 1899 Trcemmer, Das Jugendirresein

(Dementia praecox), 1900; Serieux, Gaz. hebdomad. Mars 1901; Revue
de psychiatric, Juin 1902; Jahrmaerker, Zur Frage der Dementia praecox,
1902; Meeus, Bull, de la soc. de me*d. ment. de Belgique, mars-sept.
1902; Masselon, Psychologic des dements precoces, 1902; Stransky,
tian,
Jahrb.
Psych. XXIII, 1903 Bernstein, Allg. Zeitschr. f. Psych. LX,

Meyer, British Medical Journal, Sept. 29, 1906.
2
In our experience in Connecticut the age of onset has been under 25
of the cases in the hebephrenic form 45
years of age in only 34
f.
554, 1903
develop the disease under 25 years of age, in the catatonic form 38 %,

and in the paranoid only 11 %. The average age of onset in all forms is
from one to four years earlier in the male than in the female patients.
219
220
fourths of the cases appear before the twenty-fifth year,

in catatonia sixty-eight per cent., and in the paranoid only
any way
On
the other hand, cases that cannot in

be distinguished from hebephrenia have been ob-
forty per cent.
served in patients between fifty and sixty years. The disease in the younger cases seems to take the form of a simple
gradually progressive deterioration; in the somewhat later
periods, it assumes the acute and subacute forms with
catatonic
symptoms while
;
delusion formation appears.
still
more pronounced
later the
Kraepelin reports that in the
hebephrenic form sixty-four per cent, of the cases are men,

in catatonic and paranoid forms women slightly predominate
but in our experience men slightly predominate in the hebephrenic and catatonic forms, while in the paranoid form
;
Defective heredity is a
sixty-nine per cent, are women.
very prominent factor, as it appears in about seventy per
cent, of cases reported
by Kraepelin, but
fifty-two per cent, of our cases.

different forms, being far more
more than
somewhat in the
in not
It varies
prominent in the paranoid
less prominent in the catatonic and hebephrenic

Various physical stigmata are occasionally encountered, such as asymmetries and malformations of the skull,
and equally
forms.
ears,
and
numerary
palate,
nipples,
frequently an
puerile
expression,
strabismus,
weakness.
general physical
super-
There
is
accompanying modyouth, and great sus-
earlier history of deliria
erate forms of fever, of convulsions in
to alcohol, as well as the absence of sexual

impulses and their early or unnatural development. Besides
the above evidences of a faulty endowment thirty-three
ceptibility
per cent, of the patients previous to the onset of the disease
have been only moderately bright.
At
twenty per cent,

exhibit mental peculiarities from early youth up, such as
[
seclusiveness,
affectation,
least
eccentricity,
precocious
piety,
DEMENTIA PILECOX
impulsiveness,
and moral
221
instability, while
seven per cent,
have always been weak-minded. In women, child-bearing

seems an important factor, as twenty-four per cent, of the
female catatonics become afflicted during pregnancy, or
at childbirth, but particularly the latter. This occurs in
only nine per cent, of the female hebephrenics. In ten per
cent, of the cases there is a previous history of some severe
acute illness, particularly typhoid and scarlet fevers/from
which time the patients have exhibited some change, as

increased
irritability,
susceptibility to
fatigue,
and im-
pairment of the full mental capacity. Head injuries precede a very small number of cases.
Alcoholism, likewise,
an unimportant factor, but more than five per cent, of

the male patients develop their disease while incarcerated
These and the puerperal cases are particularly
in prison.
Pregnancy
apt to develop into acute and subacute forms.
favors the paranoid forms; and child-bed, the catatonic forms.
is
Pathology.
The nature
of the disease process in de-
mentia prsecox is not known, but it seems probable, judging

from the clinical course, and especially in those cases where
there has been rapid deterioration, that there is a definite
disease process in the brain, involving the cortical neurones.
This view is further upheld by the fact that in those cases
which have been subjected to the most modern methods

of research, anatomical lesions have been found which can
be explained only upon such a basis. In a few cases this
is a reparable lesion, but in most cases the impairment of
function is permanent and progressive. This pathological
few cases that recover

and the larger number that show a permanent mental defect. The means by which these assumed changes are brought
about in the nervous system are no better known than those
that exist in epilepsy and idiocy. The relationship of the dis-
basis finds clinical expression in the
222
ease to puberty, disturbances of menstruation, child-bearing,

and climacterium, and the absence of every recognizable external cause, suggests first of all an autointoxication, which
may be in some way related to processes in the sexual organs.
Defective heredity, which exists in such a large percentage

of cases, may be presumed to create a lessened power of
resistance to the essential causes of the disease.
In the
Symptomatology.
field of
apprehension there
is
usually very little disturbance. Ordinary external impressions

are correctly apprehended, the patients being able to recognize
their environment and to comprehend most of what takes
Yet accurate tests show that very brief

place about them.
stimuli are not well apprehended.
During the acute or
subacute onset of the disease, apprehension is affected, and
there is some disorientation. This may also appear during
transitory stupor or excitement; but even in these conditions, and especially in the apparent stupidity and indiffer-
ence which characterize the later stages of the disease, it

is surprising to see how many things in the environment are
apprehended. Indeed, it is not unusual to find that patients

even notice changes in the physician's apparel, in the furNevertheless, as the disease advances and
niture, etc.
deterioration appears, apprehension, as well as other mental
phenomena, becomes perceptibly impaired.
The
orientation
know where they
mostly undisturbed. Patients usually

are, recognize those about them, and are
is
aware of the time. In stupor and in states of anxiety, the

orientation may be considerably clouded, yet it is characteristic of dementia prsecox that, even in spite of considerable
excitement, the patients continue to apprehend well.
the other hand, the delusional form of disorientation
On
may
exist (see p. 28).
Apprehension
is
always more or
less distorted
by
halluci-
DEMENTIA PRÊCOX
nations^ especially in acute
the
223
and subacute development
of
the
disease.
Occasionally, they persist throughout

entire course of the disease.
They, however, tend to dis-
appear in the end stages, though they occasionally reappear

during exacerbations. Hallucinations of hearing are most
prominent, next come hallucinations of sight and touch,
the feelings of currents, of movements, and of influence.
are distressing, and result in fear;
but later they do not excite much reaction, except during
exacerbations.
Hallucinations at
first
Consciousness is usually clear, but in conditions of excitemeirtrand stupor there is always some clouding of consciousness.
It
is,
however,
much
less
marked than one would
judge from superficial observation, as the patients later are

able to give
some
details of things that
happened
in the
interval.
On
the other hand, there
voluntary attention, which
symptoms.
The
is
pronounced impairment of
one of the most fundamental
is
controlling force of interest
is
altogether
lacking, so that the presentation which happens to be the

clearest and most distinct at any given moment is an accident of passing attention, never persistent enough to occa-
In spite of the fact that the patients perceive objects about them correctly, they do not
observe them closely or attempt to understand them. In
sion connected activity.
deep stupor and in the stage of deterioration
it is absolutely
in
to
attract
the
attention
impossible
any way. In the
catatonic form of dementia prsecox the presence of nega-
tivism inhibits
all
active attention.
This becomes evident
gradually disappears. The patients

emerging from this condition are caught stealthily peeping
about when unobserved, looking out of open doors or win-
as
the
negativism
dows, and following the movements of the physician, but
224
when an
object
is
held before
them
for observation they
stare vacantly about or close their eyes tightly.
a characteristic and progressive, but not profound,

impairment of memory from the onset of the disease. Mem-
There
is
ory images formed before the onset of the disease are retained
retention is good. Though
with remarkable persistence,
their reproduction is increasingly more difficult, unusual
stimulation or excitement may occasion the recollection
of events long since supposed to be effaced

of deterioration
recollection
is
not
free.
by the advance
The formation of
new memory images is increasingly difficult with the advance of the disease. Memory for recent events is poor.
Events previous to the onset, especially school knowledge,
may be recalled after the patients show advanced deterioration.
Some few patients keep
a careful account of the length
and elsewhere. Events

and
excitement
are
not remembered at all,
during stupor
or at most indistinctly.
The train of thought sooner or later in the course of the
of their residence in the hospital
disease
is
profoundly disturbed by the appearance of a charand desultoriness, which has already been
acteristic looseness
described (see p. 40). One finds even in the mild cases some
distractibility, a rapid transition from one thought to another
without an evident association, and interpolation of highsounding phrases. In severe cases there is genuine confusion
of thought with great incoherence and the production of new
words. In cases of the catatonic form especially, we meet with
evidences of stereotypy; the patients cling to one idea, which

they repeat over and over again. Besides, there is occasionally
noticed a tendency to rhyme or repeat senseless sounds.

In judgment there appears from the onset a progressive
defect.
While patients are able to get along without diffifail to adapt them-
culty under familiar circumstances, they
DEMENTIA PILECOX
selves to
new
225
to their inability to grasp

of their surroundings, their actions are irraconditions.
Owing
the meaning
tional.
This condition of defective judgment becomes the
The patients bebasis for the development of delusions.
lieve that they are the objects of persecution, and they may
have delusions of reference and
The lack
self-accusation.
judgment becomes still more apparent in the silliness

At first the delusions may be rather
of their delusions.
but
later
stable,
they tend to change their content freof
quently, adding new elements suggested by the environment.

Even relatively persistent delusions are constantly taking
on new meanings. Furthermore, the delusions, which at
first are of a depressive nature, later may become exIn most cases the wealth of delupansive and grandiose.
few
from
time to time, but they are usually expressed only at random.
During exacerbations the former delusions, whether depres-
sions so apparent at first gradually disappears.

delusions may be retained with further elaboration
sive or expansive,
may
again come to the foreground.
the
from
there
In
the
paranoid forms, however,

persists
beginning a great wealth of delusions, but these become
more and more incoherent.

disturbance of tb^jemoiLonaLêld
characteristic
/The
gressive,
is
and fundamental symptoms.
another of the
There
is
a pro-
more or less high-grade, deterioration of the emoThe lack of interest in the surroundings already
tionaJLlife.
spoken of in connection with the attention may be regarded

as one phase of the general emotional deterioration. Very
often
it is
this
symptom which
first calls
attention to
the^
approaching disease. Parents and friends notice that there

is a change in the disposition, a laxity in morals, a disregard
for formerly cherished ideas, a lack of affection
tives
and
friends,
an absence
of their
toward
rela-
accustomed sympathy,
226
and above all an unnatural satisfaction with their own

ideas and behavior. They fail to exhibit the usual pleasure
in their
employment.
As the disease progresses the absence of emotion becomes

more marked. The patients express neither joy nor sorrow,
from one day to another
quite unconcerned and apathetic, sometimes silently gazing
have neither desire nor fears, but
live
into the distance, at others regarding their surroundings

with a vacant stare. They are indifferent as to their personal appearance, submit stupidly to uncomfortable posi-
and even prodding with a needle may not excite a

reaction.
Food, however, continues to attract them until
tions,
far advanced.
Indeed, it is not unusual

to see these patients go through the pockets and bundles
of their friends for delicacies, without expressing a sign of recdeterioration
is
This condition of stupid indifference
ognition.
may be
short periods of irritability.
interrupted by
Early in the disease, and especially during an acute and
subacute development, the emotional attitude may be one
of depression
and anxiety.
This
may
later give
way
to
moderate elation and happiness. The latter, however, in

a few instances prevails from the onset. Yet emotional
deterioration remains a fundamental
symptom.
Parallel with the emotional disturbances are
found
dis-
turbances of conduct, of which the most fundamental is

the progressive disappearance of voluntary activity. One
of the first
activity
symptomToTthe
which
his duties
and
is
sit
disease
may
be the loss of that
He may neglect
peculiar to the patient.
for
the
unoccupied
greater part of the day,
though capable of doing good work if persistently encouraged.

Besides this characteristic inactivity, there may appear a
acts.
The patients break out wintear their clothing into strips, leap into the water,
tendency to impulsive
dow lights,
DEMENTIA PILECOX
227
break furniture, throw dishes on the floor, or injure fellowpatients, all of which seems done without a definite motive.
These states usually pass off very quickly, though in some

this tendency may be more marked for a period of a few
days.
The
inability to control the impulses is also present in the

stuporous conditions, and especially in the catatonic form of
dementia prsecox. Here each natural impulse is seemingly

met and overcome by an opposing impulse, giving rise to
actions directly opposite to the ones desired. In this condition, which is called negativism, the patients resist everyis done for them, such as dressing and undressing,
refuse
to eat when food is placed before them, to open
they
their mouth or eyes when requested, or to move in any direc-
thing that
tion.
In extreme conditions there
of urine
and
feces.
may even
be retention
This condition varies considerably in

It is not unusual to see the
intensity at different times.

patients suddenly relieved of
it,
assume
their former activity,
talking freely and attending to their own needs, and again

an interval of a few hours or days relapse gradually
into the negativistic state.
after
ânother condition is produced by the repeated recurrence of the same impulse, giving rise to a great variety
Still
movements and expressions. The verbigerations and mannerisms of the catatonic are explained in this
way. The patients repeat for hours similar expressions,
of stereotyped
monotonous grunts, tread the floor in the same spot,

dress, undress, and eat in a peculiar and constrained manner.
utter
While these symptoms vary considerably in individual cases,

unusual not to find at least some of them present in
it is
every case.
Frequently also hypersuggestibility of the will and automatism are present, particularly in the stage of deterioration.
228
The
patients are not only very pliable, but they may

echolalia or echopraxia for longer or shorter periods.
show
Some
patients, however, never show these symptoms at any time

during the disease.
One
fundamental symptoms of the disease is the

discrepancy or lack of uniformity between the emotional
attitude and the content of thought. Thus, patients laugh
and cry without apparent reason; they cheerfully refer to
of the
their attempts at suicide, and exhibit great anxiety or outIndeed

bursts of passion upon the slightest provocation.
between the ideation and the emotional

attitude gives one the impression of childishness. The whole
conduct shows many similar incongruities; the discrepancy
this discrepancy
seen between the feelings and the facial expression is called

paramimia; such as, weeping on cheerful occasions, and
laughing
when sorrow should

and crying,
prevail; also the combination
There are many other symptoms,

as mannerisms, eccentricities, and perhaps also the confusion of speech and the use of neologisms, which may be
explained on the basis of a disruption of the natural connecof laughing
etc.
tion between the processes of thought, feeling, and will. This

spontaneity frequently leads to the idea that the pa-
loss of
tients are being controlled by the will of another.

They feel
that their acts are not their own, but that they are compelled to do unnatural things. Hence some patients come to
believe that they are being hypnotized.
The
capacity for employment's seriously impaired. The

patients may be trained to do a certain amount of routine
A
fail when given something new.
few patients display artistic abilities, as, for instance, in
drawing or in music, but their efforts are characterized by
eccentricities.
They may show some technical skill, but their
work, but they utterly
productions exhibit the absence of the finer aesthetic feelings.
DEMENTIA PILECOX
Attacks either of a syncppal or an

among the most important physical
Physical Symptoms.
epileptiform nature, are
These
symptoms.
229
may
occur frequently during the course

They rarely involve alone single
of the disease or but once.
groups of muscles, or are apoplectiform in nature followed
by more or less prolonged paralyses. Occasionally these

attacks represent the first symptom of the disease. They
occur in about eighteen per cent, of the cases and are twice
as frequent among women as among men. In addition,
There is still another
hysterical attacks are also observed.
type of convulsive movement, involving the muscles of the

eye and speech, which is both characteristic and of frequent
occurrence in dementia prsecox. Some of these movements
correspond exactly to the movements of expression; wrinkling of the eyebrow, distortion of the mouth, rolling the eyes,
and those other facial movements which are characterized
as grimacing.
These movements remind one of choreic
movements and are quite independent of ideas and feelings.

may be associated with them smacking of the lips,
clucking the tongue, sudden grunting, sniffing, and coughing.
Furthermore, in the lips we observe very rapid rhythmical
movernents. More often there exists a peculiar choreiform
movement of the mouth which may be described as an athe-
There
toid ataxia.
There is usually an increase of the deep reflexes as well

as of the mechanical irritability of the muscles and nerves.
The
pupils are often dilated, particularly in conditions of

excitement, and are occasionally unequal. Not infrequently
occur in
Vasomotor changes,
pain is diminished.
circumscribed edema, and dermograph, may
stages of the disease, but are most often met in
to
sensibility
as cyanosis,
all
the stuporous states.

present.
The
Excessive perspiration
secretion of saliva
is
is
sometimes
frequently increased.
230
The
heart's activity varies, sometimes being slowed, more

often accelerated, but also sometimes irregular and weak.
The menses usually cease or are irregular. The body tem-
perature is often subnormal. In many cases there has

been detected a diffuse enlargement of the glands, which
sometimes undergo atrophy just before the onset of the

disease.
Exophthalmic goitre and tremor are sometimes
present.
Anemia and
apt to be
The
chlorosis are frequently observed.
much
disturbed during the developmental

sleep
stage, at which time there is also anorexia and the patients tend
is
nourishment; but later in the course of the

disease the taking of nourishment may vary from absolute
to take
refusal
little
of food
to
The body weight

and often to a marked
extreme gluttony.
usually falls at the onset of the disease,

degree, even in spite of the fact that the patients are
taking a sufficient quantity of nourishment. On the other
hand, the weight usually rises later and not infrequently

rapidly and to a marked degree.
group of cases comprising dementia

divided
into
three
smaller groups the hebephrenic,
prsecox is
the catatonic, and the paranoid, each of which differs someClinically, the large
what
in the grouping, prominence,
and course
of the funda-
mental symptoms.
HEBEPHRENIC FORM
The hebephrenic form
dementia prsecox is charactergradual or subacute development of a simple more

of
ized by the
or less profound mental deterioration.
An
acute onset
is
rare.
This form represents in our experience fifty-eight per cent,

of the cases of
dementia prsecox. The larger number of cases
develop under twenty-five years of age. The first symptoms

may appear at the beginning of puberty. The onset may
be so insidious that the actual date cannot be placed.
Some
DEMENTIA PILECOX
of these patients
231
do not even come under the care of the
physician until years after the onset of the disease.

The hebephrenic form should include a small group of
cases which gradually develop a simple hypochondriacal
dementia. The prominent symptom is a constantly increas-
and mental incapacity, accompanied

by all kinds of morbid sensations, which finally compel
the patients to desist from any sort of activity. At the
same time there develops an emotional indifference and
ing feeling of physical
general
languor
without
hallucinations
or
pronounced
delusions.
Symptomatology.
Usually the patients first complain
of headache and insomnia, which are soon followed by a
gradual change of disposition.
They
lose their
accustomed
self-absorbed, shy, sullen, and

and obstinate. They may
or
irritable
seclusive,
perhaps
be rude and assertive, or perfectly indifferent. They become
activity
and energy, becoming
careless of their obligations, thoughtless,
They accomplish nothing, but rather
sit
and unbalanced.
about unemployed,
apparently brooding, or they leave their work to go to bed,

Others,
lying there for weeks without evident reason.
instead
x>f
this inaction, exhibit
a marked
restlessness,
and
continuous
They leave their work, stroll
about or travel from place to place, especially at night.
Others, with increased sexual passion, indulge in illicit and
effort is impossible.
promiscuous intercourse.
During this period, which
may extend through
several
months, remissions are common, when for a short time the

patients improve greatly and may even appear natural.
This period, on the other hand, may rather be characterized
by alternating periods
and elation of increasusually show premonitions of the
of depression
ing severity. Women

disease during the menses.
232
Sometimes the onset
is
characterized by a period of
marked
The patients become apprehensive, dejected,

and
reserved.
sad,
They are troubled with thoughts of
death, and sometimes suddenly attempt suicide, often
depression.
in a peculiar
manner.
are usually hypochondriacs,

and complain of nervousness and weakness; they search
quack medical literature and frequently ascribe their troubles
They
to former masturbation.
There is also a mistrust of the

environment and a feeling that they are being watched, imposed upon, or badly treated. But most striking is the
emotional indifference with which the patients express and
defend their morbid ideas.
Many
cases develop
no
further.
The more
severe cases
at this time begin to show hallucinations, especially of hearThe patients are annoyed by
ing, and less often of sight.
strange noises, unintelligible voices, unfavorable comments

upon their personal appearance; they hear threats and
and
imprecations, music
commands from God.
singing, telephone messages,
They may
and
also see heavenly visions,
on the wall, dead relatives, frightful accidents, and

deathbed scenes. Occasionally they smell various odors,
crosses
especially illuminating gas
and sulphur.
They may
which lead them to
ex-
beperience various hypersesthesias

lieve that the head is double, that the throat or nose is
occluded, that the genitals are being consumed, or that the

bowels are all bound together.
At the same time delusions become a prominent part of

the picture and are mostly of a depressive character. The
patients believe themselves guilty of some crime, accuse themselves
of being murderers, claim that
damned,
unfit to live,
never recover from
they are
lost,
are
have practised self-abuse, and can
effects.
They suspect their surdetect
in
the
roundings,
poison
food, are being worked upon
its
ill
DEMENTIA PILECOX
233
others, their thoughts are not their own, friends

turned against them and are trying to do them harm,
by
have
some
are
and
them
they
being harconstantly,
watching
followed
are
Women
assed by various agencies.
by men
who would ravish them. Later in the course of the disease,
and occasionally from the onset^ the delusions are expansive;
one
is
the patients then regard themselves as prominent individuals

the President, the Son of God, the Creator, the possessor of
:
They converse with God, are the Saviours of

Some patients are conand
men,
possess all knowledge.
trolled by sexual ideas, fancying perhaps that they are bethe universe.
trothed to prominent individuals. Men believe themselves

possessed of many wives, or regard themselves as the center
of attraction for all
These delusions
women.
may be augmented by numerous
fabri-
cations; the patients claiming that they have been President for a century, chief commandant in various engage-
ments, have been knighted, that they have been in heaven,

have gained possession of the key of hell, have just returned
from a
visit to
Mars.
These fabrications, together with the
delusions, gradually recede to the background.
they become
and
still
first
less fantastic,
then incoherent,
scanty, until finally, in the
advanced stages
less
more
At
numerous,
of the disease, there remain only incoherent residuals of
elicited,
never be expressed except when

or during excitement.
Some
insight into their condition is often expressed at
former delusions which
may
by the patients. They are conscious that a change has

come over them, and often complain that the head feels
strange, benumbed, or empty. These ideas may be expressed
in connection with somatic delusions, when they will claim
first
that the brain
is
rotting, the
different in every
memory failing, that they are

much confused. But
way, or are very
234
even this scanty insight gradually disappears as the disease

progresses.
is
In those forms of the disease which develop slowly there

at first neither clouding of consciousness nor disturbance
of orientation.
and general
with
and
In the acute or subacute onset, cloudiness
disorientation
pronounced
unite in the clinical picture

hallucinations and delusions, anxiety
may
and incoherence
of thought.
The patients
mistake persons, do not appreciate where they are, and are
unable to record passing events. Physicians are regarded
as enemies trying to kill them, working upon them with
restlessness,
are confined in a prison for some grave

offence, or are among the heavenly hosts, surrounded by
electricity, etc.
They
saints.
The
at
first
train of thought in the gradually developing cases is

very little disturbed, the content of speech being both
coherent and relevant; but later in the disease and with

progressive deterioration there develops the characteristic
of thought and desultoriness, often combined
with the use of neologisms and embellishments.
looseness
The memory at first suffers only moderately. Memory of

and the chronological order of events is well re*
tained for a long time. Some of the patients are able to
earlier life
with surprising accuracy the exact definitions in geography and many historical events almost word for word,
as committed to memory years before. But with the progtell
ress of the disease there is
of the store of ideas.
an increasing impoverishment
The
impressibility of memory is retained, but the patients fail to make use of it, because there
is a total lack of interest.
Without this there is no incen-
and thought, and they fail to observe

on
about
them. As the disease progresses,
going
increasing limitation of thought. For this same
tive for observation
what
is
there
is
DEMENTIA PRJECOX
235
reason past experiences are seldom recalled, and so finally

fade from memory; though it is not unusual for patients,
in reaction to unusual stimulation, to recall events that
seemed to have
entirely passed
from them.
The defect in judgment appears early, develops rapidly,

and becomes profound. This may not be evident while
the patient is confined at home, or during the early part of
the residence in an institution, as long as his thought is
employed with familiar facts, and his range for action limited.
becomes apparent, however, when he leaves the trodden

path and attempts to adapt himself to new circumstances.
He is unable to reason, to perform mental work, to recog-
It
nize contradiction, or to overcome obstacles.

can also be seen in his tendency to formulate
The defect
and hold to
senseless, incoherent delusions.
In emotional attitude the most prominent and permanent

Whenfeature is that of emotional dulness and indifference.
ever we find emotional activity it is increasingly self-centered.
At first there is usually more or less depression, with anxiety,
peevishness, and often irritability. Exaggerated expressions of religious feelings are apt to be prominent, the patients
being devout, praying frequently, reading their testaments,

at first apparently in the spirit of penitence, but later because they are led by God or ordained to do some special
work. The sexual feelings very often play a prominent
role, particularly in those who have been addicted to the
habit of masturbation.
matters,
Thought may center about sexual
when they enjoy obscene
literature,
write long
letters to acquaintances, and give expression to their

lascivious feelings, masturbate, and solicit intercourse.
Female patients are more apt to associate with their own
sex.
In both sexes these feelings are apt to disappear later

Later in the disease the de-
in the course of the disease.
236
lusions, both expansive and hypochondriacal, are expressed

without display of emotion. Patients fail to express emotion
at the loss of friends, at the visits of relatives, or at an un-
usual supply of food, fruit, or candies. They live a very

empty life, devoid of any cares or anxieties, and without
thought for the future.
In conduct and behavior, the most characteristic sympthat of childish silliness and senseless laughter. The
voluntary activity is inconsistent and lacks independence.
tom
is
At one moment patients
are increasingly headstrong, at the
next as supremely tractable.

all sorts
pearance, perform
such as prowling about
all
They neglect their personal apand foolish deeds,
of outlandish
night, setting fire to buildings,
throwing stones to break windows, and travelling about without evident purpose. They may even run away and secrete
themselves, or as unexpectedly
forget
their obligations,
pable of
and
demand some one in marriage,

are completely inca-
finally
comprehensive employment. A
found throwing stones into trees because the
A student ran from his
spirits annoyed him.
continued and
young man was

voices of evil
mates to a graveyard and covered himself with leaves in

order to obtain aid in committing his ivy oration. A girl
of fourteen attempted to stab her lover, believing him to be
unfaithful.
young married woman
solicited intercourse
among gentlemen friends, even bringing them to her

for that purpose in the presence of her
husband and
home
children.
The
patients are very often seen to converse with themselves, sometimes aloud, while associated with this there is
almost always
laughter.
characteristic
silly
This
silly
laughter
is
a very
prominent and
symptom. It is unrestrained,
on
all
occasions
without
the least provocation, and
appears
altogether without emotional significance. Besides these
actions, mannerisms, such as peculiarities of speech and
is
DEMENTIA PILECOX
237
movements, eating and walking, are often present. A few

of the mannerisms characteristic of the catatonic may prevail:
echolalia, echopraxia, stereotyped expressions and
movements.
The speech presents peculiarities indicative of looseness

Their remarks may
of thought and confusion of ideas.
be
artificial,
containing
many
stilted phrases, stale witti-
The incisms, foreign expressions, and obsolete words.

coherence of thought becomes most evident in their long
drawn out sentences, in which there is total disregard for
grammatical structure. The structure changes frequently,
and there are many senseless interpolations. All this becomes even more apparent in their letters, which are verbose with frequent repetitions, while the handwriting is
characterized by a marked lack or a superfluity of punctuation marks, shading of letters,
and copious underlining.
During the onset of the disease

Physical Symptoms.
the condition of general nutrition suffers. There is a loss
of weight,
is
and some patients even become emaciated.
appetite
strained by
The
Patients eat sparingly or not at all, repoor.

suspicion and fear, or because they are so directed
by God.' The sleep also is much disturbed, both by anxiety

and distressing dreams. The pupils are occasionally dilated.
The tendon reflexes may be exaggerated, and vasomotor
disturbances may be present. The skin loses its normal
healthy appearance, becoming dry and flaccid. The menses
Later in the course of the disease
cease or become irregular.
the appetite returns and often becomes excessive. At this
time the weight often rises rapidly, and the emaciated condition is frequently replaced by great corpulence. The
menses also reappear and remain normal, and the evidences
of muscular and nervous irritability disappear.
Course.
The course of the disease in the hebephrenic
238
form
is
characterized by
all sorts
of variations.
Suitable
treatment during the active stages at the onset usually
But there develops later

produces some improvement.
a condition of uniform dementia, which may be permanent,
or interrupted by repeated exacerbations.
Occasionally
there develop conditions of pronounced excitement with
mischievousness, talkativeness, clownish behavior, laughing,

giggling, a tendency to sexual acts, and senseless wandering
about.
In other cases there develop profound clouding,
with impulsiveness, greater incoherence of thought, dancing,

smearing, destructiveness, and assaults. These conditions
are usually of short duration. They may recur suddenly
and without warning. The degree of mental defect increases
from year to year, more especially following the transitory
periods of excitement.
Of the cases that are admitted to insane institutions,
about seventy-five per cent, reach a profound degree of deteri-
These
are dull, indolent, apathetic,

to
apprehend the surroundings.
anergic, sluggish,
They remain seated for hours wherever placed, are incapable
oration.
patients
and
fail
of caring for themselves, are untidy, have to be dressed
and
undressed, and led to meals. At table they are slovenly,

spattering and smearing themselves with food. They give
little evidence of voluntary activity. They seldom speak,
are unproductive and mute; occasionally they may be seen
to laugh sillily or repeat to themselves some unintelligible
but
word or
syllable.
Their attention
for a short time.
attracted with difficulty and held only

External objects usually fail to make an
is
Questions are apparently uncomexciting intelligible answers. These
impression upon them.
prehended,
seldom
are usually monosyllabic
however,
may
and
irrelevant.
be correctly carried out.
Simple directions,
Relatives
and
ac-
DEMENTIA PILECOX
quaintances
may
not be recognized.
edge are retained in
many
239
Bits of former knowl-
cases for a long time, such as
and geographical facts and the ability to solve prob-
historical
In this respect the patients often surof

one.
One
patients was able to name the islands
prise
of the Pacific and give the names of their sovereigns.
Another, who for two years had been mute, unable to care
lems in arithmetic.
my
through the day with bowed

of
his surroundings, recognized
unmindful
head, entirely
a college mate, straightened up with an air of dignity, and
laughed at some college jokes. In the course of time even
for himself, untidy, sitting
such
relics of
nothing
left
former mental activity disappear, and we have

but the unproductive vegetative organism.
A few patients retain some remnants of mental activity,

they are quite unbalanced,
of hallucinations
and
silly,
delusions.
and present the
but
residuals
Instead of the extreme
some patients continue restless and

an
babble with silly laughter.
incoherent
producing
stupidity and indolence

talkative,
During the periods of transitory excitement these patients

are very apt to be aggressive, breaking windows and attacking fellow-patients, to masturbate shamelessly, pull out their
hair,
and frequently show homicidal tendencies.
Usually
requires several years before the patients reach this stage

In cases with an acute onset it may appear
of dementia.
it
within a year.
In about seventeen per cent, of the cases the degree of deterioration is not as far advanced.
These patients, after the
subsidence of the more acute symptoms, show a certain
amount of mental activity and are capable of some employ-
ment under supervision. They are oriented and have a

certain amount of insight into their mental incapacity, but
lack mental energy and the power of application. They
have
little interest
in the surroundings,
no care for their
240
own
and no thought for the future, but are conand be cared for. In conduct they are apt
livelihood,
tented to live
many mannerisms.
to present
The judgment
tant events
edge, but
psychosis
is weak and memory defective.

Imporbe retained, together with school knowl-
may
memory
is
for events subsequent to the onset of the
very poor, while they are quite incapable of
The hallucinations and

acquiring additional knowledge.
delusions of the various stages of the disease for the most
part entirely disappear. While retained in a few cases, they
are of little importance to the patients, rarely influencing
As in the other grades of dementia, so here,

a tendency for the deterioration to increase as the
patients advance in age. This is especially noticeable foltheir behavior.
there
is
lowing short periods of excitement, which are apt to be coincident with menstruation. At these times the patients
show motor
and sometimes violence, with a reappearance of former delusions and

hallucinations, talkativeness, silly behavior, and incapacity
for employment.
The delusions are more apt to be expansive, changeable, and incoherent, but at times there may
be verbigeration and repetition of single phrases. The
restlessness,
with great
irritability
actions are usually purposeless.
few of these cases leave the institution apparently recovered, but upon reaching home the patients fail to employ
themselves profitably.
They spend much time in reading,
evolving impractical schemes, and pondering over abstract
and useless questions. Or, if employed, they show a lack
of interest, are unbalanced, and unable to advance in their
Later their field of thought beprofession or occupation.
comes more circumscribed and their relations with the

outside world correspondingly meagre. They become seclusive and so much disinterested in intellectual work that
DEMENTIA PILECOX
241
they pass their time in purely machine-like action, engaged

in gardening or transcribing.
Finally in about eight per cent, of the cases the
symptoms
of the disease entirely disappear, leaving the patients apparently
in their normal condition.
Not
all of
these cases should be
regarded as perfect recoveries, because in some instances there

have been recurrences in later life, followed by deterioration.
In
still
other cases there has been a stunting of mental de-
velopment.
ambition.
The
patients have been unable to realize their

Young men and women whose academic or
collegiate courses
have been interrupted by the psychosis
find themselves unable to enter into active business or prolife.

These patients are able to care for a farm
or a small business where there is little demand for in-
fessional
In this way we lose sight of the mental

shipwreck following dementia prsecox, because enough mental capacity is retained to permit them to maintain the
tellectual
work.
battle of life in their chosen
narrow
field.
CATATONIC FORM (Catalonia)
The catatonic form of dementia prsecox is especially

characterized by stuporous states with negativism, hypersuggestibility,
and uniform muscular
tension;
excited states
with stereotypy and impulsiveness; leading in most cases, with

or without remissions, to mental deterioration.
This form
comprises in our experience about eighteen per cent, of

the entire group of dementia prsecox.
Alzheimer, in fatal cases of
acute delirium which he believed belonged to catatonia,
has described profound changes in the cortical neurones

of the deeper layers.
The nucleus was much swollen, its
membrane
wrinkled, and the cell body shrunken, with a

tendency to disappear. In the glia there was an increase of
242
fibres
which fastened about the
cell in
a peculiar manner.
Nissl, in all prolonged cases of catatonia, has demonstrated
extensive changes in the cells, which vary considerably in

degree as well as kind. Even in cases where there appeared
to be no atrophy in the cortex, he found a number of cells
which had undergone degeneration. In the deeper layers

of the cortex very large glia cells were found which normally
Elsewhere the cortex
appear only in the outer layers.
contained glia
cells
with slightly stained
cell
bodies
and
large pale nuclei with small vesicles, which were in close

approximation to the degenerated nerve cells, not only at
body, like the satellite cells, but also

surrounding it. This pathological lesion and the type of
glia cells are not peculiar to catatonia, but they are found to
the base of the
cell
a striking degree in the deeper cortical layers in this disease.

The onset of the psychosis is usually
Symptomatology.
subacute, with a condition of mental depression quite
The
similar to that observed in the hebephrenic form.
patients for several weeks before the onset may have ap-
peared unusually quiet, serious, or even anxious, complaining of difficulty of thought, of headache, or of peculiar
sensations in the head. Besides this, they may have suffered
from insomnia and
loss of appetite,
and have
left their
work
because of nervousness and general ill health. Gradually

the patients show great anxiety, and express fear of impendTheir religious emotions become more promiand
hallucinations
and delusions appear. A voice
nent,
from heaven directs them to do all sorts of things. One
patient is commanded to spit to the right, and another to
convert sinners. There is a vision of Christ on the cross,
the Virgin Mary appears, faces are seen at the window and
pictures on the wall, spirits hover about, some one speaks
from the radiator, and there is music in the next room. They
ing danger.
DEMENTIA PILECOX
243
hear their children cry for help. Some one calls their name,
and they hear their own thoughts. Little birds speak to
Specks of poison are detected in the food; sulphur

fumes are set free about them; some one pulls at their hair,
them.
injects
The
water into their limbs, or applies electricity to them.

delusions are usually of a religious nature, are inco-
herent and changeable from day to day. The patient is

persecuted for his sins, a priest has come to anoint him be-
God has
fore he dies.
transferred
him
to heaven, where he
surrounded by angels. He no longer needs food, as

Christ has forbidden him to eat.
He is. eternally lost,
is
possessed of the devil, has caused destruction of the whole

world; all are dead; he is surrounded by spirits, his children
is
are lost, the wife false, his body has been transformed into
mules' hoofs, his hands into claws, his brain has been drawn
and while hung to a cross, his limbs and body have run
away like molten metal. The delusions may later become
expansive, though they are occasionally expansive from the
The patient then believes himself transformed into
onset.
off,
can create worlds, has lived for thousands of years, possesses all knowledge, can cast out evil
spirits, is a millionaire, owns railroads, etc.
Christ, has all power,
During the
of
earlier stages of the disease
some
peculiarities
movement and
action appear, particularly constraint,

increase to a state of muscular tension. The
which may
patients assume constrained attitudes, holding the arms
in awkward positions, as in the form of a cross, etc., standing or walking in an awkward manner, all of which may
be symbolical of their ideas. One patient stood for hours
with hands behind him and head thrown back, staring
and another lay in the form of a cross

upon the floor. In some there is a tendency to execute
rhythmical movements, such as rolling the head from side
fixedly at the ceiling,
244
to side, or expectorating at stated intervals in a fixed direction.
In this period of depression the consciousness

clouded, orientation
do not apprehend
is
is
somewhat
and the patients

what goes on about them. They
home or in an institution, but they
slightly disturbed,
clearly
may know that they are at
to appreciate the mental condition of their fellowpatients, mistake those about them for friends and acquaintfail
ances, or they claim that everything is changed and that

they cannot understand the mystery of it all. Some believe
themselves translated to heaven, that they are in a

or in a foreign city.
is
Although the
surprisingly good.
be mistaken for Christ or some one else, he
impressibility
physician
is
loose and somewhat desultory and reasoning

The memory for remote events is well retained
is
Thought
is difficult.
and
cloister,
may
always remembered.
Occasionally genuine falsifications of
are seen.
memory
The emotional
delusions
jected,
and
attitude is at first quite in
hallucinations.
anxious,
complaining,
The
accord with the
patients are sad, de-
irritable,
distrustful,
and
sometimes threatening; when interfered with, they are very

apt to become violent. Occasionally sexual excitement
leads to masturbation and obscenity.
Later they lose their
become indifferent or contented with their

and
the delusions are expressed without
environment,
emotion. Some patients are even cheerful and happy, or
early anxiety,
ecstatic.
The disturbances in conduct and actions are very striking.

The patients cease work and lie listlessly about; they laugh
without apparent reason, indulge in excesses, neglect themselves, and sometimes utter threats.
Many patients pray
constantly
and devote much time
to attending church ser-
DEMENTIA PR.ECOX
245
a few attempt suicide or assault friends or relareason.

without
tives
vices; not
in
Following this preliminary period of the disease, which

most respects is quite similar to that in the hebephrenic
form, the more characteristic catatonic symptoms appear;

namely, the catatonic stupor and the catatonic excitement.
In at least one-third of the cases these symptoms appear at

the very onset of the disease.
The catatonic stupor is chiefly controlled by the symptoms negativism and automatism. Negativism often occurs first in the form of mutism, when the patients refuse
to speak. They begin by speaking low, breaking off in the
midst of a sentence or answering in monosyllables, then
whisper unintelligibly, and finally refuse to speak

Some patients in this condition may be peraltogether.
may
they
suaded to write or sing answers to questions. When addressed they remain with closed eyes or staring fixedly at
some distant object, apparently paying absolutely no attention to the physician.
Even shaking patients, pinching
them, or prodding them with a needle fails to elicit a re-
sponse, except
when
in pain;
may become
patients may move
then the
more
closely pressed together or the
away
indifferently.
Further evidence of negativism
is
lips
seen in the obstinate
which the patients make to every

attempt at handling them. They resist being put to bed
and being taken out, dressing or undressing, moving forward or backward, opening the eyes or closing them. The
active resistance is well demonstrated by suddenly withdrawing the hand which has been placed against the patient's
forehead, when it springs forward with a jerk. The physical
origin of this resistance becomes more apparent in those
cases in which the desired action is only elicited by com-
and
persistent resistance
246
manding the patient contrariwise. One may get a patient

to open his eyes by urging him to close them tightly, to lower
the hand by telling him to lift it, etc.
Even the most natural impulses are resisted, as seen in
their stubborn refusal to wear shoes or stockings, in the
tendency to sit on the floor rather than in a chair, or to sleep
under the bed and not in it, and go to the closet by the
longest route. They prefer to eat another's food, and some
persist in crawling into the beds of others.
of
Finally the re-
and the retention of urine and feces are evidences
fusal of food
more extreme negativism.

The absence of food
months.
The former may last for

week will not overcome
for a
this disinclination to take food voluntarily.
It is not
un-
usual for this form of negativism, as well as the others, to

appear and disappear suddenly. Sometimes the patients
transferred to another ward, or will regiven a different bed. The urine and feces
will begin to eat
main
may
in
bed
if
if
be retained until there
few cases
it is
is
marked
distention.
In a
necessary to overcome this by catheterization
and enemata.
usually associated with negativism an unusual
uniformity of the muscular tension which is exhibited
in several ways, especially in the extraordinary uniformity
There
is
of position maintained
by the body or its various parts. In

this condition patients maintain the same position for weeks
and even months. The usual position is on the back, with
limbs stretched out, the eyelids closed with the eyeballs
upward and inward, or with the eyes open staring
fixedly in the distance, the face mask-like with lips slightly
rolled
and
same time protruded. The hands are

very often clenched, as if there were permanent contractures,
the fingers producing pressure marks on the palms.
Plates
1 and 2 represent two stuporous catatonic patients.
The
closed
at the
PLATE
1.
Muscular tension
iu catatonic stupor.
DEMENTIA PILECOX
247
maintained this uncomfortable position for

with
his head thrown far backward, eyes
weeks,
tightly
While in
closed, and face mask-like with protruded lips.
this condition he required daily feeding by nasal tube.
The
boy
rigidly
woman
maintained this same position for over four years

without a known voluntary attempt to change it. The
body and head are slightly bent forward with the eyes staring
directly in front of her, the lips protruded, the arms flexed,
and hands so tightly clenched that cotton must be placed
in the fists to prevent pressure sores.
While in bed she
lies
straight upon the back with knees strongly adducted and

arms drawn closely to the chest, but with the fists in the
same constrained position. During this long period it has
been necessary to feed her by spoon. Others lie rolled up

like a ball, with head thrown forward and knees drawn to
the chin. In the extreme condition these patients may
be rolled about or
movement, as
lifted
and
laid across
rigid as a piece of wood.
some
object without
Muscular tension
is
not evenly distributed, but is most frequently seen in the

hands, arms, face, and lower limbs. The gait is often influenced
move
at
by
all,
this condition,
some patients being unable to
falling rigidly to the floor
when
raised to their
feet; others walk
stiffly, with unbent knees, on tiptoes, or

on the outer side of the feet with the body bent forward or
backward. The movements are usually slow and constrained.
Sometimes the counter impulses seem to be suddenly overcome and the movements become rapid.
The
less
hypersuggestibility
is
seen especially in catalepsy, and

and echolalia, the latter of
frequently in echopraxia
which are usually
of short duration.
In the echolalia and
echopraxia the patients simply repeat in a wholly mechanical
and monotonous manner what they may happen to

They imitate or mimic
hear or see done in their presence.
248
every act of some person in their environment. Questions

asked are only repeated. The condition of catalepsy is
She had
well seen in the patient depicted on Plate 3.
been placed in this awkward and very uncomfortable posiThe feet are
tion, which she maintained until relieved.
drawn backward, and elevated so that the toes

barely touch the floor; the arms are elevated and drawn
backward and the head is extended as far as possible.
These disturbances of the will become evident when one
separated,
requests the patient to protrude his tongue, in order that

it may be punctured with a needle.
Although he sees the
needle and comprehends that you are threatening him with

it, yet upon request he shoots out his tongue without hesitation,
and
command
will
repeat the experiment as often as you

frowns when pricked, but is unable to
He
him.
suppress the impulse released by the
These
suggestibility
during
command.
and hyper-
apparently opposite states of negativism
may
the
pass directly from one into another

stupor. Absolute silence suddenly
of
stage
to
loud and unrestrained shouting or to incessant
gives way
the
prattle;
patients awake from the stupor and talk as if
nothing had happened, and again in a few hours relapse into

their former stuporous state.
Sometimes these changes
can be brought about by mere suggestion.

are quite characteristic of catatonia.
Interrupting the stupor or following it,
even preceding
is
it,
we have
Such changes
and sometimes
the catatonic excitement, which
by impulsive actions and stereotyped movecondition of excitement usually develops
characterized
ments.
The
and
often follows the initial condition of depresrapidly

sion already described. The patients suddenly leap from
bed, tear their clothing, break the furniture, race about the
room, shouting or singing, throw themselves upon the
floor,
PLATE
2.
Muscular tension
in catatonic stupor.
DEMENTIA PR.-ECOX
249
rotating the head from side to side, breathing rapidly,

churning saliva in the mouth, or making a peculiar blowing
sound.
They may run about the house
for hours at
a time,
While lying
striking the bed or the wall in a certain place.
in bed the body may be swayed regularly back and forth,
or the bed tapped at a certain place at regular intervals
In walking they are apt to assume peculiar attitudes.
One
a
patient stood for hours against the wall in the form of

"
the Father, the Son, and the Holy
cross, repeating,
Ghost
77
;
another, holding his nose tightly with his hands,
uttered a monotonous grunt for hours at a time. Mingled
with these movements are seen numerous impulsive move-
ments when the patients jump about from one object to

another, pounding themselves, knocking their heads against
the wall, wringing their hands, jumping up and down on
the bed, and stamping on the floor. All of these most varied
movements are carried out with great strength and recklessness,
without regard for the surroundings or themselves,

for the most part purposeless and impulsive.
In the
and are
midst of their ceaseless tramping about the room they may

suddenly grab at the clothing of the physician or assault a
fellow-patient.
During this excitement the patients are
very untidy and filthy, expectorating in the food, smearing
with feces and food, urinating in the bed and clothing,
and evein washing themselves with urine. Sexual excite-
ment veiy often accompanies this condition.

Mannerisms in facial expression and speech are especially
characteristic of these catatonic states.
Accompanying
speech there
is
a peculiar gesticulation, winking of the eyes,

and nodding of the head, and drawing of
senseless shaking
The voice assumes a peculiar

The manner of speech may be
The content of speech
explosive.
the muscles of expression.

intonation or may quiver.
scanning, rhythmical, or
250
is
often quite characteristic, consisting of a series of senserepeated in a fixed measure or rhyme. Words
less syllables
or short sentences are likewise repeated; the words may

be clipped or the last syllable drawn out. Usually these
expressions bear no relation to the trend of conversation.
One
patient,
when asked how he
"I see you,

Another common
I see
minutes,
felt,
repeated for three
you."
disturbance
is
the
inconsequential
The patients react to every

answering of questions.
but
not
The answers
question
according to its sense.
are
generally
more or
less
irrelevant, though occasionally they have

remote reference to the question as though
the desired information was avoided.
example:
How do you
Did you
feel this
"
sleep well?
(the
name
many of us are
day
of the
an
of
"
The lady with the black

"
is her name?
Clara
What
fellow-patient).
How many
room? "Three" (four). How

"
"
the room ?
Three (four). What
in the
there in
month
is
"
(indicating a nurse) ?
"
clothes
(dressed in white).
Swanson"
following
It is a fine morning."
morning?
It was a cold night."
Who is this
lady
windows are there
The
is
it?
"September 35" (October
5).
How much money have I here? " Two dimes " (a quarter).
How much now? "Two dollar bills" (one dollar bill),
etc.
Such responses
in a medico-legal case
would be very sug-
gestive of simulation, but their apparently close relationship to negativistic states should in such cases lead one to
search for other negativistic signs.
In their voluntary speech genuine desultoriness is often

seen (see example, p. 40). Neologisms, the repetition of
senseless expressions, and the use of sentences that are wholly
devoid of connection are frequent, while at the same time
PLATE
3.
Cerea
flexibilitas in catatonic stupor.
1.
Catatonic writing showing verbigeration.
DEMENTIA PR^COX
251
the patient affects lisping and grunting, or speaks in a falsetto

Agrammatism is sometimes present, in that the
voice.
patients
seem unable to construct sentences and use only
infinitives in speaking.
Verbigeration is also a frequent symptom in the catatonic

excitement as well as in the stupor. It consists in the use
of many motor expressions, the tendency to stereotypy,
and the
repetition of similar impulses.
repeat for hours

sions, or single
The
patients will
and even days at a time senseless expressyllables, usually in the same monotonous
manner, though sometimes modified by shrieking or singing them. Verbigeration is especially noticeable in the
voluntary writings of the patient, which are
striking
by
excessive underlining, shading,
made
still
more
and addition
of
symbols.
Catatonic stupor often passes abruptly into catatonic
excitement and vice versa. The excitement is more apt to
Sometimes one state replaces the other
precede.
a few minutes or hours.
The degree
for only
of stupor or excitement
varies considerably in individual cases.
During the stage of catatonic stupor and excitement, the

is somewhat clouded, but the patients seldom
lose their orientation completely.
In spite of the fact that
seem
of
and
unconscious
unable to comprehend
they
quite
consciousness
awake from a condition

and give the names of those about them, telling
the day and the month, and showing surprising knowledge
of what has happened within their limited range of obsertheir surroundings, the patients will
of stupor
vation.
Partial insight into the conditions of stupor
ment
is
frequently expressed
by the
refer to their peculiar acts as foolish,
help doing them.
patients,
and
excite-
when they
but say they could not
Others say that they
felt
compelled to
252
do what was requested, that they could not remain quiet

it was done, or that they are commanded by God but
whatever the explanation, it is apparent that their peculiar
until
acts are distinctly impulsive
and not the outcome
of reason-
ing.
The
emotional attitude during these distinctly catatonic

no striking disorder. They are mostly in-
states exhibits
different as to their delusions and conduct.

Threats make
no impression upon them. Provided negativistic symptoms are not present, they will not wince when threatened
with a burning match or an open knife, and will not even
wink when the eye
is
approached with a needle.
Occasion-
ally there are observed changeable states of childish petulancy, irritability, or silly elation and ecstasy.
In some cases elevated temperature, varying between one hundred and one hundred and two
degrees during the acute onset of the symptoms, may persist
Physical Symptoms.
Cyanosis, dermography, and localoften

occur.
Convulsive attacks are also
sweating
encountered in a few cases, mostly at the onset. There
for
two or more weeks.
ized
during the stage of depression. This

becomes more prominent during the stupor and may reach
is
loss
of weight
extreme emaciation in
spite
of
forced
feeding.
Later,
stupor, the weight rises.

of
deterioration
the patients usually bethe
stage
During
come quite fleshy. During stupor the skin is cold and
clammy, the heart's action slow and feeble, and the bowels
sometimes
constipated.
Course.
beginning
during
The usual course
in the catatonic
form
is
de-
pression and stupor, followed by excitement, passing into

dementia. In a few cases the stupor is immediately fol-
lowed by dementia without the intervention of the characteristic
excitement.
Occasionally the excitement precedes
DEMENTIA PILECOX
the stupor and
may even appear
253
at the very onset of the
disease.
prominent feature in the course of the disease, which

rarely appears in other forms of dementia prsecox, is the
Remissions for a few days or a few hours occur
remissions.
in almost all of the cases.
The consciousness
of the patients
becomes perfectly clear. They apprehend and remember

events, are quiet and rational, and often express a feeling
of illness.
At
these times close observation discloses a
manner and actions, an inconsistent

a lack of full appreciation of their
and
emotional attitude,
previous condition. These brief remissions occur most
frequently in the states of excitement and are both less
frequent and less complete in stupor. In at least twenty
certain constraint in
per cent, of all the cases, the remissions are long enough for
the patients to seem to have completely recovered. Yet,
in these cases, one often detects peculiarities which indicate
not complete, such as irritability, seclusiveA reforced, affected, or constrained manners.
that recovery
ness,
and
is
lapse usually occurs within the
may
first five
years,
though
it
not come within fifteen years.
The outcome
in fifty-nine per cent, of the cases is ulti-
In these cases,
mately pronounced mental deterioration.
the stupor and excitement disappear and the hallucinations
and delusions become less prominent, but the patients give

numerous evidences of dementia. They are stupid and
indifferent, and have lost their mental activity.
They are
able to comprehend simple questions, but they lack mental
The memory is defective, the judgment poor, and
initiative.
they are unable to acquire new knowledge. They have no
regard for themselves, their personal appearance, or their

future.
They remain contented wherever they happen to
be,
and never express any
desires.
They
are wholly unfit
254
employment, as they have no idea of how to

work. Upon questioning, and in a few cases voluntarily,
delusions and hallucinations are expressed; the former are
usually expansive but quite incoherent, and without effect
for intellectual
upon the conduct
Some
of the patient.
of the patients are very inactive, remaining stupidly

most of the time, sometimes muttering to them-
in one place
but taking no interest in their surroundings. Other

patients are active, restless, and unbalanced. In both of
selves,
these groups, and especially in the latter, we find mannerisms.

The movements lack freedom, are constrained and peculiar;
the patients walk on tiptoe, along cracks, or with bent limbs,

with head thrown forward and with cramped hands. The
head
is
usually held in peculiar positions.
When
sitting,
they always assume fixed positions, shaking or nodding the

head at regular intervals, making a blowing noise with the
to meals only through certain
doors, or perhaps backwards. The mannerisms are especially marked in dressing and at table. They may eat
lips or grunting.
They pass
with great rapidity,
filling
the
mouth
to
its fullest
extent
before swallowing.
Others eat very deliberately, waiting
a certain interval between mouthfuls, perhaps counting
three, each bit of food being prepared and carried to the
mouth
in a certain definite
manner.
Many
patients eat
with their hands, others hold the knife and fork in some
peculiar fashion.
One
of
my
patients refused to eat unless
he had been allowed to stand on his head and crawl under

the table.
Similar mannerisms are evident in speech
and
In speech, neologisms may prevail, especially

the
during
transitory periods of excitement, when in addition there may be a genuine word- jumble.
writing.
The
deterioration gradually deepens, particularly following the short periods of excitement, which appear in most
DEMENTIA PRÊCOX
255
At these times the patients are restless, irritable,

cases.
and threatening, and express delusions of persecution. The
speech, in addition to shouting and laughing, shows marked
confusion.
the
prominent, as seen in
aggressiveness, and even homicidal
Impulsiveness also
destructiveness,
is
attempts.
In twenty-seven per cent, of the cases the dementia is of a

Here the patients return to clear consciouslighter grade.
home, and in a
few cases resume their former occupations. But a profound
change in character has occurred; their former mental
and
ness, are quiet
orderly, able to return
listless, dull, and lack energy

and endurance. Their judgment is defective. They are
cleanly and orderly in conduct except for a few catatonic
vigor does not return, they are
Some
mannerisms.
distrustful,
childish
and
or
of the patients are very quiet, seclusive,
self-conscious;
while others are somewhat
silly.
These cases not infrequently present periodical attacks
of
excitement very similar to those exhibited in manic-depressive

These attacks are of short duration, not more
insanity.
than a few days or weeks, but the intervals vary greatly.
The
patients become loquacious, distractible, less accessible,

are elated, and have a pressure of activity in which the movements are mostly purposeless, stereotyped, and character-
These periodical attacks may not

develop until after several years have elapsed. There should
also be included here a series of cases in which there is a
ized
by impulsiveness.
regular alternation between brief periods of excitement and

brief intervals.
In women these attacks seem to bear some
menses (menstrual insanity). The patients

begin to laugh much, to wink their eyes, and to wander
about; then there suddenly develops an extremely active
relation to the
excitement.
The weight
falls
rapidly,
sometimes
five
to
256
eight pounds in twenty-four hours. The improvement comes

almost as rapidly, although toward the end of the attack
a slight diminution of the dazedness and activity.

The patients become clear and orderly, but for a time conthere
is
tinue very quiet, apathetic, and rather stupid, and usually

fail to gam an insight into their condition, although they
may be able to recall several incidents of their psychosis.
The weight
is regained rapidly.
These attacks may recur
at intervals of one to three weeks for a long time. In the
greater number of these cases the intervals become shorter,
but in either event there ultimately develops a condition of

profound dementia.
About thirteen per
cent, of the cases
seem
to recover.
Some
of these patients manifest slight peculiarities in conduct
and a change
which is apparent only to those

A number of these cases
closely associated with them.
later in life suffer from another attack, terminating in
in character
dementia.
Unfortunately,
will recover,
become
it
what
impossible to determine what cases

cases will have long remissions or will
is
deteriorated.
This
much can be
said,
however,
that those with an acute development, also those in which

the stupor or excitement is very pronounced, are more apt
to have a remission.
Marked improvement is not a favorable
indication, provided that with the clearing of consciousness,

there is not a corresponding improvement in the emotional
attitude;
if
senseless delusions are expressed without cor-
responding effect or excitement;
typy persist; and
if
mannerisms and stereo-
a recurrence of periods
of excitement.
Prolonged stupor of itself does not necesindicate
sarily
deterioration, as patients have remained in
finally, if
there
is
stupor from three to five years.

The fatal termination of the catatonic cases usually occurs
DEMENTIA PILECOX
as the result of
culosis is
some intercurrent
disease, of
257
which tuber-
the most prominent.
PARANOID FORMS
In both the hebephrenic and catatonic forms of dementia prsecox delusions are characteristic, but they tend
In the paranoid forms of the
to fade within a short time.
disease,
on the other hand, delusions and usually
lucinations persist for

of
a more or
mains
clear.
less
many
also hal-
years, although there are evidences
rapid deterioration while consciousness re-
The paranoid forms, comprising twenty-two
per cent, of the entire
group of dementia prsecox, consist of
two groups of cases.

First Group (dementia
This group is
paranoides).
characterized by the persistence of numerous incoherent
and changeable delusions of both a persecutory and an
expansive nature associated with a moderate degree of
excitement, and a rather rapidly developing dementia.
The onset of the disease, as in the
Symptomatology.
other forms, follows a period of headache, malaise, and insomnia with a rapid loss of energy and often irritability.
The patients act peculiarly, are unusually devout, seem
depressed and anxious, and remain alone. Very soon they
divulge a host of delusions, almost entirely of persecution;
people are watching them, intriguing against them, they
are not wanted at home, former friends are talking about
them and trying to injure their reputation. These delusions

are changeable and soon become fantastic. The patients
claim that some extreme punishment has been inflicted upon
them, they have been shot down into the earth, have been
transformed into spirits, and must undergo all sorts of torture.
Their intestines have been removed by enemies and

little at a time; their own heads have
are being replaced a
258
been removed, their throats occluded, and the blood no longer

circulates.
They are transformed into stones, their countenances are completely altered, they cannot talk, eat, or
walk like other men, etc.
Hallucinations, especially of hearing, are very prominent
during this stage; fellow-men jeer at them, call them bastards, threaten
them, accuse them of horrible crimes, and
numerous slanderous telephone messages are overheard.

Occasionally faces and forms are seen at night, or a crowd
of men throwing stones at the window.
Foul vapors may
be thrown into their bedding.
The patients show agitation; they are anxious, restless,
quarrelsome, and emotional. They laugh, cry, and sing.
The
In conduct, they may

is not disturbed.
kinds of serious and outlandish acts, attempting
orientation
perform
all
and committing arson.

The emotional attitude soon changes and becomes more
and more exalted. At the same time the delusions become
The
less depressive and more expansive and fantastic.
patient in spite of persecution is happy and contented, extravagant and talkative, and boasts that he has been transsuicide, assaulting persons,
formed into the Christ; others
will
ascend to heaven, have
many lives, and traversed the universe. They have

the talent of poets, have been nominated for President,
and have represented the government at foreign courts.
These delusions may become most florid, foolish, and ridicuA patient may say that he is a star, that all light and
lous.
darkness emanate from him; that he is the greatest inventor ever born, can create mountains, is endowed with
lived
the attributes of God, can prophesy for coming ages, can

talk to the people in Mars; indeed, is unlike anything that
all
has ever existed.

Associated with these variegated and ever changing ex-
DEMENTIA PILECOX
259
pansive delusions there are delusions of persecution almost

as absurd and extreme, but expressed without corresponding emotion. Patients smilingly complain that they have
been deprived of their limbs, have been pierced with thousands of bullets, and been thrown into hell, where they were
exposed to furnace flames. Suggestions for many of these
delusions may be obtained from pictures on the wall or from
reading.
The
hallucinations also
Angels descend from heaven and
God
become more extreme.
commune with them
daily,
them, the President directs their conduct,

beautiful visions are displayed at night which are full of
also talks to
meaning.
These patients are usually talkative and express freely
Some of them fill hundreds of sheets
their many delusions.
of paper trying to describe them.
At
first
they are quite
coherent, but later there is such a wealth of ideas loosely

expressed that it is difficult to follow them. They wander
and show
same ideas. Questions, however,
are answered in a coherent and relevant manner. Later
in the course of the disease the speech becomes more and
more difficult of comprehension, because of the number
of peculiar phrases and neologisms to which they attach
The writings likespecial significance and freely repeat.
wise become more and more unintelligible.
The patients rarely possess insight into their condition.
The consciousness usually becomes somewhat clouded, es-
aimlessly about from one delusion to another,
frequent repetitions of the
pecially later in the disease.
Orientation as to place is
least disturbed, but people are soon mistaken and often
designated as celebrated personages, and all conception of
time is lost.
Patients recognize relatives and can give a fairly
where they are. They may recall

some past knowledge, but they soon become unable to use
clear statement as to
260
it
in reasoning
They
and utterly
to follow long conversations.

cannot apply themselves to any mental work. The
show an
patients
feelings,
fail
exaltation of the ego with heightened
they are self-conscious, with an important manner,

In emotional attitude they
special attention.
and demand
are almost always exalted, rarely depressed, although a few
show restlessness, some
irritability, and occasionally

often
in
some passion,
connection with the menses. Increased sexual excitement is also common. Some patients
are able to do some mechanical work, but need supervision
patients
because of their capriciousness and fickleness.
There is very little physical disPhysical Symptoms.

turbance except the loss of weight and insomnia at the onset, faulty nutrition,
irritability
Course.
The
and
occasionally increased vasomotor
with easy blushing and blanching.

The course is progressive without remissions.
signs of mental deterioration
may appear
within a few
months, and are usually well marked by the end of two years.
The patients may for a long time retain clear consciousness and partial orientation, but the content of thought
becomes thoroughly incoherent and there is a lack of energy
and plan in their activity, which incapacitates them for all
mental application. While active and somewhat interested
display a self-conscious
From this stage of dementia there may be no
serenity.
further progress for a number of years.
Occasionally transitory exacerbations of excitement or depression occur.
in
their
environment, they
still
Finally there may be periods when the patients disclaim

their delusions and refer to them as foolishness, but at the
same time they do not regain

Second Group.
There
clear insight.
is provisionally grouped here a

which are characterized by fantastic
delusions usually accompanied by numerous hallucinations
larger series of cases
DEMENTIA PRÊCOX
261
which are more coherently developed and expressed for a number of years, when they either become incomprehensible or dis-
appear
altogether, leaving the patients in
a condition
of
mod-
erate dementia.
The
Symptomatology.
first
those of despondency with some
to appear are
self-accusation.
The pa-
symptoms
tients are troubled with thoughts of
death and religious
doubts; they are unusually devout, and seek religious adThey fear that they have done wrong, have committed
vice.
some
crime, or are suffering the penalty of self-abuse. Coherent delusions of persecution develop gradually; people
watch them, peculiar actions are noticed, acquaintances
are less friendly, and children on the street jeer and laugh
at them, perhaps mimicking their manners. Strangers on
the street turn and stare. In public places, in the cars, and
at the church, they observe peculiar acts which refer to them.
They believe themselves libelled by the newspapers. They
understand these mysterious occurrences and
will shortly
Affairs at
expose the offenders and bring them to justice.
home are unsatisfactory; the children are different, and the
husband or wife
is
unfaithful.
Hallucinations) especially of hearing, rarely of sight, are

prominent at this time, aiding in the elaboration of the
Enemies take advantage of their confinement

by standing below the window, calling them all sorts of names,
delusions.
announcing that they are to be imprisoned, that they have

committed murder, and are to be put to the rack. Voices
and from under the floor, stating

that they are wretches and outcasts of society. Very often
the noises really heard, such as the blowing of whistles and
are heard from the walls
the ringing of
delusions.
are misinterpreted in accord with their

complain that the food contains poison
bells,
They
which they can
taste,
they suspect phosphorus in the tea
262
and detect kerosene on the
They
clothing.
notice that
their clothing is changed, buttons are missing, there is a

rip in the coat and a pocket torn.
Objects in their surround-
ings are changed in order to confuse them.
Delusions of physical influence become particularly prominent. Many common somatic sensations, such as twitching of individual muscles, headache, specks before the eyes,
pain about the heart, and cramp in the bowels are all evidences of such influences wielded by their enemies. The
explanations of these somatic sensations are often most
An itching of the foot is sufficient evidence
fantastic.
that a poisonous powder has been blown into their shoes,
pain in the back indicates that they have been shot there
while asleep, a frontal headache is the result of poisonous
vapors, which are set free in the room at night in order to
A tremor of the fingers is prodestroy their intellect.
duced by means of electric currents sent through the

air.
Something is placed in their food to create sexual
excitement.
Their persecutors employ the most varied means in pro-
ducing physical discomfort.
All
known
agencies are men-
tioned, as, magnetism, hypnotism, X-rays, telepathy, and

electricity.
Organs of the body are removed and then re-
placed out of order, and the intestines are shrunken. It is

quite characteristic for the patients to refer to these physical changes by some invented names, such as, ugly duberty,
Others complain that their

minds are influenced, their thoughts are gone, they have
no control over their thoughts, which, in spite of themselves,
snicking, lobster cracking, etc.
are always
to others.
attribute the origin of such thoughts

"
Frequently they complain of
drawing of the
evil.
They
thoughts," and they may say that they don't know whether
their thoughts are their own or suggested by some one else.
DEMENTIA PILECOX
Sometimes
especially
their thoughts
when
reading.
263
become audible (double thought),

Their thoughts are
known
to the
whole world.
Ideas of spirit-possession are often a prominent feature.
Here the enemy enters and takes possession of the body,
causing the bones to crack and the head to rattle; obscene
remarks proceed from the stomach; their ears are filled by
sorts of noises
all
made by
cause the testicles to
fall
and
these spirit-possessors.
the throat to dry up.
They
In connection with the delusions of influence there deall cases more and more pronounced expanThese are as variegated and fantastic as
persecution. The patients have been awarded a
velops in almost
sive delusions.
those of
prize for bravery
and now
rule the country, possess beautiful
and are betrothed to the king, etc. God daily

appears to them and gives them a blessing. They have
dresses,
recently been intrusted with millions which they are to invest in mining. They have consummated an immense
which they are president. All of the many delusions

expressed by the patients are at first coherent, and may be
partially systematized; but in the course of a few years, they
tend to become somewhat incoherent, and at the same time
trust, of
the hallucinations become more agreeable.

The consciousness during the development of these delusions,
mains
and
clear,
for a long time afterward, perhaps years, re-
and the patients are
oriented.
coherent, but centers about the delusions.
able at
first
to offer
and
to
Thought
The patients
some basis for the delusions, to

show some " method " in their
is
are
refute
ideas;
as deterioration appears gradually in the course of
several years, thought becomes confused, and the delusions
objections,
but
later,
incoherent, contradictory, and changeable. There is rarely

insight into the disease.
Many patients appreciate that they
264
are not normal, but their defects
and ailments are rather
regarded as the work of their persecutors.

The emotional attitude is at first one of depression, with
anxiety and combativeness, but later this gives way to a
amount
certain
of happiness
and
cheerfulness, with con-
There may be transitory outbreaks of

siderable egoism.
In some cases stuporous
anxiety as well as of irritability.
states
The
have been observed.

conduct
is
mostly in accord with the delusions; the
patients are suspicious, journeying about to get rid of their

enemies, applying to police for protection; or, taking the
own hands, they attack supposed persecutors

Others for
expose them through the papers.
matter in their
or attempt to
self-protection contrive a sort of
armor
for themselves, place
metals in their shoes or wires in their clothing to divert the

In accord with expansive delusions
electrical currents, etc.
they may decorate themselves in fantastic costumes, adorn

themselves with badges, assume a superior air, and use highflown language.
Furthermore, during the course of the disease peculiarities

of conduct develop, such as, grimacing, striking gesticulations,
mannerisms in
eating, walking,
and speaking, as
well as signs of negativism or of stereotypy.

Course.
The duration of the disease extends through
many years. It is sometimes possible to discern certain
stages in its development: at first a change of disposition,

then a prominence of delusions of persecution, later the
appearance of delusions of grandeur, indicating the onset
away and entire

the delusions. Remissions in the symptoms
The outcome is always deterioration. The
of deterioration,
collapse
may
of
occur.
and
finally the
fading
rapidity with which the dementia develops varies greatly.

Usually some signs of dementia appear within two or three
DEMENTIA PILECOX
265
On the
other hand, there are cases which deteriorate

within a few months, and there are others which do not
years.
dement for a number of years.

In some cases the delusions gradually
fade, are never exor

are
wholly denied, and at the same
pressed,
forgotten
time there appears some insight. But in all these cases
there
still
remains some impairment of
ment, apathy, and a

activity.
memory and
judg-
energy and
Or the delusions and hallucinations may be reloss of the characteristic
tained, while the patients become quite indifferent to them,

rarely complain of persecutions or show agitation.
They are usually capable of employment, and sometimes
and
"
"
are even industrious, the former
Pope becoming a trusted
"
"
farm-hand, and the
queen a good seamstress.
More frequently the outcome
is
characterized
by an
in-
creasing confusion of thought, when the delusions become

more and more incoherent and unintelligible, while the
conduct increase with a tendency to occaIf the detesional states of excitement and impulsiveness.
peculiarities of
rioration advances further, the patients

of silly, quiet dementia.
may
reach a stage
Diagnosis of dementia praecox.
There are not only no

pathognomic signs of dementia prsecox, but even some of the
more characteristic signs of the disease, such as, negativism,
automatism, stereotypy, and mannerism, occur in other
dis-
and other organic psychoses,

as well as in some of the infection psychoses, and even hi
manic-depressive and epileptic insanity. Hence the diagnosis
must rest on the entire picture and not upon any single
eases; for instance, paresis, senile
symptom.
cesses
is
all
may
While it is possible that different disease proexhibit at times similar groups of symptoms, it
altogether improbable that these
same
diseases will at
times resemble each other, both as regards the manner
266
which the symptoms develop, their course, and their outcome.

The slowly developing cases of hebephrenia must be
distinguished from acquired neurasthenia. This differentia-
in
tion depends especially

tia,
the
silliness
upon the presence
of signs of
of the hypochondriacal ideas,
demen-
especially
sexual hypochondria, faulty judgment, emotional apathy,

and the fact that the patients do not improve with quiet and
The emotional apathy of the hebephrenic

stands out in contrast to the increased emotional irritability
of the neurastheniac.
Finally, any evidences of hallucina-
relaxation.
tions,
of
automatism,
dementia praecox
The
or
stereotypy
distinctly
indicate
(see also p. 155).
dementia praecox, occurring in middle life, from paresis in which the physical symptoms have
not yet appeared, may be quite difficult. The catatonic
differentiation of
occasionally occur in paresis

catalepsy,
and
are
mutism, verbigeration,
stereotypy
by no means
as varied and characteristic as in catatonia; while the general
symptoms that
incapacity and genuine weakness of will is more prominent

in contrast to the eccentricities and the unruliness of the
catatonic.
is
Furthermore, the mental deterioration in paresis
apt to be more rapid and more profound and character-
by greater disorder of the apprehension, orientation, and

impressibility of memory, while these faculties in comparison with the emotional stupidity and the weakness of judgment in dementia praecox are retained for a relatively long
ized
time, although they may be temporarily overpowered by negativism. The appearance of definite hallucinations and of
dementia praecox. The

speech disturbances of the paretic may be closely simulated
by the mannerisms of dementia prsecox; even epileptiform
persistent
mannerisms speaks
for
and apoplectiform attacks may occur
in dementia praecox.
DEMENTIA PR^COX
267
In such doubtful cases one must depend upon the lymphocytosis in the cerebrospinal fluid as determined by lumbar
and the microscopic examination
puncture
of the
fluid
(see p. 103).
In the acutely developing cases of dementia praecox, the

clouding of consciousness and the confusion of speech often
render it difficult to distinguish amentia. Here one must
depend upon the presence of negativism, stereotypy, and

automatism.
If the latter are
present in amentia, they are not

marked. In amentia, the patients are more natural in their
The
acts, less constrained, and not silly and eccentric.
of
orientation and impressibility
memory is far more dis-
turbed in amentia than in dementia praecox. The amentia

patient, in spite of his best efforts, is unable to solve long
mental problems, loses the thread in long conversations, and

indulges in incoherent reminiscences, yet he is able to answer
some questions rapidly and to the point.
On the other hand,
the dementia prsecox patient answers in a silly manner or

perhaps not at all.
Again at times he surprises one by
and his thoughtful, bright remarks,

a difficult problem and recalls correctly
his correct conversation,
or he even solves
historical
and geographical
facts.
In amentia the emotional
exceedingly changeable from depression to exvice versa, while in dementia praecox, even
attitude
is
altation
and
during excitement, a certain emotional stolidity and apathy

The amentia patient may not have a very accuprevails.
rate knowledge of the surroundings, yet he attends to and
watches what takes place ; but in dementia praecox the patient exhibits remarkably little interest in those things
that he comprehends well.
Finally, in
amentia there
is
always a history of some exhausting etiological factor,

which only occasionally antedates dementia prsecox.
Beginning cases of catatonia
may be mistaken
for epileptic
268
befogged states, particularly when an epileptiform attack has

occurred. The negativism of the catatonic contrasts with
the anxious resistance of the epileptic, while orientation is

much more disturbed in the epileptic. Silly answers to
simple questions and rapid and correct obedience to commands speaks for catatonic. In epileptics an anxious or
ecstatic emotional attitude prevails.
The epileptic is much

and attempts at escape,
more apt to make frequent assaults

while the impulsive acts of the catatonic are purposeless
and manneristic.
The
greatest difficulty arises in distinguishing the depresinsanity from the periods

which one encounters at the onset of the hebe-
sive phases of manic-depressive
of depression
phrenic and the catatonic forms.

hallucinations
and
The
early appearance of
many
delusions, especially
ideas of physical influence, and the retention of a clear consciousness speak for dementia prsecox, as well as an emotional attitude which does not correspond to the depressive
character of the delusions.
senseless
The
catatonic patient remains
quite indifferent during the visit of a relative, while in manicdepressive depression the feelings are apt to be intensified.
Hypersuggestibility of the will may exist in both conditions,
but a manic-depressive patient will not upon request protrude his tongue for the purpose of having it perforated with
a needle. The uniform lamentations that sometimes occur
in manic-depressive
persistent
depression are the expressions of a
and overwhelming
feeling of sadness,
and not
the result of a senseless persevering impulse. The conditions of negativism of the catatonic and of anxious resist-
ance and retardation of the manic-depressive are at times

distinguished only with difficulty. In the former there is
uniform, rigid, and stubborn resistance to every passive
movement, and if pain is produced by pricking the eyelid,
DEMENTIA PR^COX
269
a simple withdrawal without effort at defence;

while in retardation the passive movements are mostly
permitted. In case the retarded patient shows some resistance
there
is
he does not persist in returning his hand to the same position,

and if one threatens to approach him he utters an outcry,
shrinks back, or defends himself.
Voluntary movements
in catatonic stupor are rare, but when executed are carried
out without delay, and at times even rapidly, except when

these movements are made by request, then there is always
In retardation, all voluntary movements are carried

out very slowly. There is sometimes a certain resistance
delay.
due to apprehension and fear, but this is active.

The differentiation between manic-stupor and catatonic
stupor
istic
is
and depends upon the character-
quite difficult
happy temperament,
distractibility of the attention
by the environment, the susceptibility to command, the

accessibility to conversation, and finally the occasional
purposeful and frolicsome character of the movements of
manic-stupor in contrast to the silliness, indifference, insusceptibility,
and the
senseless impulses of the catatonic
stupor.
The excitement
from
of the catatonic
the excitement of the
is
to be distinguished
manic phases
of manic-depressive
In the catatonic excitement the clouding of coninsanity.

sciousness is less marked than in the manic excitement,
the patients being partially oriented, even in the greatest
excitement, while in the extreme manic states there is
complete disorientation. On the other hand, the speech of

who has less motor excitement is more senseless
the catatonic
and
difficult to follow
than that of the manic who has ex-
treme motor excitement.
The
catatonic speech abounds in
verbigerations and stereotyped expressions and is free of comments upon the surroundings, while the speech of the manic
270
presents the characteristic flight of ideas, and is centered

upon, or drawn largely from, the immediate surroundings.
readily distracted by the surroundings,
while the attention of the catatonic cannot be. The emo-
Also attention
is
the manic
tional attitude of
is
exalted, frolicsome,
irritable, while that of the catatonic
happy, and
is
The movements
indifferent.
and
childishly
silly,
of the catatonic
are purposeless, frequently repeated, in contrast to the pressure of activity of the manic, in whom the movements are
always purposeful, related to the surroundings, dependent

upon ideas, impressions, and emotions, and always appearing
In catatonia there is no parallel between the
in new forms.
excitement in speech and that in movement; for instance,
the patient may be extremely productive, lying quietly in
bed, or he
extremely active and not utter a word.

activity of the catatonic is more apt to be
may be
The increased
room or of the bed, while that

limited only by his confines, and in addition
to this the individual movements of the catatonic tend to be
limited to one corner of the
of the
manic
is
manneristic, stilted, unnatural, and associated with silly

impulses; those of the manic, natural and more comprehensible.
The extreme
excitement of the paretic
may
resemble closely
In addition to the history of the
the catatonic excitement.
development of the disease, the age, and the physical signs,

paresis may be recognized by the more profound clouding
of consciousness, the greater disorientation,
of the impressibility of
Dementia
terical
ness, the
attitude,
memory.
where there have been hysfrequently be differentiated from
prsecox, especially
must
The
insanity.
attacks,
hysterical
and disorder
latter fails to
show the
desultori-
weakness of judgment, the indifferent emotional
and the
similarity
and purposelessness
in the con-
DEMENTIA PILECOX
271
duct of the dementia prsecox patient. All of these symptoms stand in contrast to the shrewdness, capriciousness,
and the purposeful obstinacy

of the hysteric.
Finally, pronounced hallucinations and
delusions favor dementia prsecox. But there is still a large
number of cases, which present at the outset clear symptoms of hysteria, but which later show unmistakable evidence of the deterioration of dementia prsecox. The very
same condition may exist in manic-depressive insanity, in
epilepsy, in paresis, and in brain tumor, which would favor
slyness,
keenness, tyranny,
the view that in constitutionally defective individuals the

early stages of these diseases may resemble very closely
the picture of hysteria.

The distinction of the paranoid forms of dementia prsecox
from pure paranoia depends upon the lack of system, the
rapid development of fantastic delusions commencing with

prominent hallucinations; while in paranoia the onset is
very gradual, sometimes extending over one year with only

a few hallucinations. The delusions in dementia prsecox
are extremely fantastic, changing beyond all reason, with
an absence of system and a failure to harmonize them with
events of their past
furthermore, the delusions of physvery prominent. In paranoia the delusions are largely confined to morbid interpretations of real
events, are woven together into a coherent whole, gradually
life;
ical influence are
becoming extended to include even events of recent date,

while contradictions and objections are apprehended and
In emotional attitude the dementia prsecox
explained.
patients soon show clear and marked changes,
depression
or silly elation, sexual excitement, and remissions; while
in paranoia the emotional attitude is uniformly natural,
the
demeanor
capable
of
is
almost
occupation
normal, and the patients are

In paranoia
a long time.
for
272
there
less
be partial remissions when the patients react

actively to the delusions, but the delusions never
may
disappear.
In the absence of history of the early
life
and
of the psy-
chosis, imbecility may be confused with the end stages of

dementia prsecox. The recognition of dementia praecox
then depends upon the presence of exacerbations in which

dementia praecox signs appear and occasional utterances
which evince extensive

Treatment.
earlier
knowledge.
Our meagre knowledge
of the causes of
the disease restricts the indications for treatment to the

individual symptoms. The cases which develop acutely
or subacutely demand careful watching in order to prevent
and
suicidal attempts.
Unless this can be
the
aid
of
with
a
sufficient
accomplished
nursing force at
home, it is best that the patient be sent to a hospital. Cases
self-injuries
form with gradual onset can be much

more safely cared for at home. At the onset in all forms of
the disease the patient must be placed in a quiet and restful environment, free from all irritating circumstances,
of the hebephrenic
and
in the charge,
if
possible, of a judicious nurse.
It is
usually advisable that the patient should not be in charge

of a member of the family.
In the acute and subacute
cases,
bed treatment should be regularly prescribed.
The insomnia is best combated by the simplest measures, as

hot baths upon retiring, warm liquid nourishment, or the
hot or cold pack. If the patient does not secure six or seven
hours sleep by the simple remedies, one may resort on alternate nights to sparing doses of some hypnotic, as, trional,
veronal, somnos, chloral, or paraldehyde. These drugs
should not be given for long periods without being alternated.

Conditions of excitement are always best controlled by the
prolonged warm bath (see p. 140), at
first
preceded by a pre-
DEMENTIA PILECOX
273
-^
to -$ grain, or
liminary dose of hyoscine hydrobromate
in
same
the
dosage. The extreme
scopalamine hydrobromid
excitement sometimes encountered, especially in the catatonic

form, may not yield to the prolonged warm bath, in which
event one can often successfully employ hot or cold packs
(see
These
p. 321).
packs,
however,
are
not
applied
risk, and usually require the supervision of

a physician. But in the employment of any sedative it
must be borne in mind that the remedy is not curative, and,
therefore, it is not advisable to employ high doses in order
without some
to wholly curb the excitement.
If it
seems essential to
secure quiet where these other measures have failed, one

may occasionally resort to a hypodermic of hyoscine hydro-
bromate
ment
-L^J-Q
is
still
with morphine sulphate J grain. If the exciteunabated, nothing remains but confinement
padded room with careful watching. Simple persuasion

on the part of a well-trained, tactful nurse or physician often
in a
succeeds in bringing about quiet, at least temporarily; but

this requires great patience, a kindly disposition, and selfcontrol.
While the condition of nutrition demands careful attenit becomes parthe

states.
The patient
ticularly urgent during
stuporous
should eat a liberal quantity of easily digested food. In
tion during the early stages of the disease,
order to estimate the state of nutrition such cases should
be regularly weighed at least once a week. During stupor

with refusal of food, the patient should not be permitted
to go without food and water for more than three days.
If the patient is illy nourished, one should resort to feeding
by stomach or nasal tube at the end of thirty-six hours.
The patient may be fed artificially two or three times daily,

the total amount aggregating two quarts of milk with six
raw eggs, and, if need be, an ounce of olive oil, varying
T
274
quantities
of
meat
juice,
and stimulants,
particularly
whiskey.
The excretory
functions
must be
daily watched, particu-
larly during the stuporous states, when patients retain the

feces and urine.
During the acute manifestations of the
frequent high flushings of the lower bowel with

normal saline solution are well recommended.
disease,
During the periods of despondency at the onset of the

disease, in addition to the bed treatment already referred
the patient should be given an opportunity at times
during each day to leave the bed for short periods and exer-
to,
Furthermore, simple methods of occupying the mind,

at the same time affording some diversion, as, reading, playcise.
should be a part of the daily

routine.
Friendly encouragement, with a frank discussion
of the various delusions and hallucinations, persistently
ing games, needlework,
etc.,
carried out by a kindly and tactful nurse and physician, is

not the least important feature of the treatment, and must
not be overlooked.
As the more acute symptoms improve and the
fear
and
then be allowed
increased activity subsides, the patient may

to leave the bed for longer periods, but at the
same time the
graduated exercise and mental application should be increased. The whole effort of the physician should then
be directed to developing remaining mental capacity and

preventing further mental defect. This requires a considerable
amount
of specialized attention in the individual cases
order to prescribe means that at the same time are

adapted to the patients' needs and traits and also are
in
suited to their environment.

sufficiently
so
that
they are
homes or to their full

must not overlook the
liberty.
Very many patients improve

able
But
to
return
to
their
in advising this, one

and in
possibility of exacerbations,
DEMENTIA PILECOX
women
275
the possibility of pregnancy, and the resumption of
excessively
burdensome home
advanced grades
surveillance.
An
mental shipwrecks
of doors.
of
cares.
deterioration
The cases exhibiting

must be kept under
essential feature of the

is
care of these
healthful employment, preferably out
DEMENTIA PARALYTICA
VI.
DEMENTIA PARALYTICA/
(Paresis)
or general paresis of the insane, is
a chronic psychosis
of middle age, characterized by progressive

mental deterioration with symptoms of excitation of the central
nervous system, leading to absolute dementia and paralysis,
and
pathologically, by
a fairly
definite series of organic changes
in the brain and spinal cord, probably the result of some toxin,
in the origin of which syphilis is most often an important
factor.
2
ilized
The
nations and
from
five to eight
Etiology.
disease
is
unknown among the
unciv-
is most
Europe
and North America, hence, it seems to be a disease of
modern civilization. In America, the disease comprises
prevalent in western
per cent, of the admissions to insane

institutions, but in some European cities, notably Berlin
and Munich, the paretics average thirty-six to forty-five per
The disease is somewhat

more prevalent in large cities and manufacturing centers,
while it is relatively rare in farming communities. The promale admissions.
cent, of the
Voisin, TraitS de la paralysie gSneYale des alie'ne's, 1879 ; Mendel, Die

Mickle, General Paralysis of the
progressive Paralyse der Irren, 1880.
Insane, 2. ed. 1886. v. Krafft-Ebing, Nothnagels spezielle Pathologic
u. Therapie, Bd. IX, 2, 1894.
Ilberg, Volkmanns klinische Vortrage, 161 ;
Binswanger, Deutsche Klinik, VI,

2
f.
2, 59,
1901.
Diefendorf, Brit. Med. Jour., No. 2387, p. 744.
Psy.,
XXVI,
XIII, 2 u.
Psy.,
1900.
3.
XIV,
2.
Gudden, ebenda.
v.
Wollenberg, Archiv.
Krafft-Ebing, Jahrb. f. Psy.,
Oebecke, Allgem. Zeitschr. f Psy., XL. Hirschl, Jahrb. f.

Bar, Die Paralyse in Stephansfeld, Diss., Strassburg,
.
321.
276
DEMENTIA PARALYTICA
277
portion of male to female paretics is 1 to 3.9 to 7. This disproportion has recently gradually decreased. Negresses show
a striking tendency to the disease; in Connecticut, the

negress paretics are ten times more prevalent than the
female white paretics. Women suffer more often from the
depressive form and least often from the agitated form, and
in them the disease lasts longer.
Our average age of onset
hundred and seventy-two cases is forty-two years.

Kraepelin in two hundred and forty-nine cases finds that it
occurs preeminently in middle life, as eighty-one per cent, of
the cases occur between thirty and fifty years, the disease
in one
before twenty-five or after fifty-five years

average age of onset in our women was two years
rarely appearing
of age.
The
younger than in men, and one-third of the women became

afflicted between thirty and thirty-five, while one-fourth of
the cases occurred after
finds that the onset in
perience,
the onset
is
Kraepelin, however,
averages later. In our ex-
fifty years.
women
earlier in syphilitic
and
alcoholic
women.
Our natives are slightly more prone to paresis

than our foreign-born.
l
*
Recently a number of cases of juvenile paresis have been
reported occurring between the ages of ten to twenty years
in which hereditary paresis, syphilis, and alcoholism are
Clinically, the juvenile form is chardeterioration
of three to four years' duraby simple
tion with numerous paralytic attacks, choreic disturbances,
prominent
factors.
acterized
and paralyses.
The disease afflicts
1
chiefly the unmarried,
Alzheimer, Allgem. Zeitschr.
f.
progressive dans le jeune age, 1898.
1901, 21.
v.
Psy., Ill, 53.
Rad, Archiv
Frolich,
f.
Psy.,
Psy., LII, 3.
Hirschl,
82.
XXX,
and among the
Thiry,
De
la paralysie
Wiener Klin. Wochenschr.,

Mingazzini, Monatsschr.
f.
Uber allgemeine progressive Paralyse der Irren
vor Abschluss der koerperlichen Entwicklung, Diss., 1901.
278
women especially prostitutes; in our experience prostitutes

are forty-five per cent, more prone to the disease than other
women. Married women are usually childless. Not infrequently the disease occurs in man and wife; sometimes
tabes is present in one and dementia paralytica in the other
and paresis occasionally exists in the parents. The male
paretics come from all classes and from most professions
and trades, though the disease is more prevalent among hotel
and saloon keepers, quarrymen, carriage and hack drivers,
bakers, sailors, hostlers, mechanics, masons, salesmen, and
clerks, and least prevalent among farmers, servants, and
Defective heredity
comparatively insignificant, except in juvenile paresis, as it occurs in only

factory employees.
is
per cent, of cases.

Among the causes of the disease, syphilis is statistically
the most prominent. Its prevalence varies, according to
fifty
various authors, from one and six- tenths per cent, to ninetythree per cent., but most observers place it between thirty-
and
In our experience it existed

in fifty-two per cent.
Gudden in the Charite, and Kraepelin
at Heidelberg cannot establish a clear history of syphilis in
four
sixty-five per cent.
more than thirty-four per
cent, of
male
paretics.
In other
but five and five-tenths per

psychoses, we
cent, of the cases.
Therefore, there seems to be some relabetween
tionship
syphilis and paresis, a view which receives
find syphilis in
further support not only by the experiments cited by KrafftEbing, in which nine paretics inoculated with syphilis failed
to develop secondary syphilic lesions, but also
by the
clinical
observation that paretics infected with syphilis during the

This latter is
disease do not show secondary manifestations.
now doubted by Marchand, Gabiana, and Garbini, who have

reported seven cases in which paretics developed syphilis.
Other apparently significant facts are the infrequency of
DEMENTIA PARALYTICA
paresis in
its
women
frequency
and Catholic priests,

and the occurrence of pare-
of the better classes
among
man and
279
prostitutes,
Other important causes are excessive

in sixty per cent, of our cases, head
existed
which
alcoholism,
injury twenty-three per cent., and mental shock. Finally, a
sis in
wife.
factor which cannot be overlooked

life
with
its restless
is
the ensemble of modern
overactivity and
insufficient relaxation,
coincident with the struggle for existence in large cities,

and the common excesses in eating and drinking.
In view of the uniform course of the disease
Pathology.
leading to dementia and nervous paralysis, accompanied by

a general and extensive destructive process, involving not
only the central nervous system, but also the general vascular
system, and to a limited extent the internal organs of the
seems probable that we have to do with a toxic

process. There exist symptoms of excitation of the neurones,
body,
it
their rapid destruction, gradual sclerosis, occasional exacer-
bations of the symptoms, and the possibility of a regeneration of the neurones, all of which can be reproduced by
experimentation upon test animals with any toxic material
which causes a destruction
of the neurones.
These anatomi-
wholly in accord with the clinical observations ;

the
gradual onset, great clouding of consciousness,
namely,
rapid or gradual deterioration, and marked remissions, some
cal facts are
which almost approach complete recovery. The vascular

and the broad extent of the process indicates that
the toxin reaches the neurone by means of the blood vessels.
The involvement of the kidneys, heart, and the entire vascular
of
lesions
system, the fragility of the bones, the alternate loss and increase of the body weight, ending at last in great emaciation, all speak for the profound general disturbance of
nutrition of which the mental are obviously the
but not the only symptoms.
most
severe,
280
The sudden and high
elevation of temperature, as well
as the prolonged subnormal temperature,
and
finally the
paralytic attacks, judging from our experience in eclampsia,

myxedema, and uremia, can best be explained by intoxicaViewed in
tion arising from disturbance of metabolism.
this light, the
pathology of paresis resembles that of myxe-
dema, diabetes, osteomalacia, and acromegaly, except that in

these diseases the toxin does not involve the nervous tissue.
The character
of the toxin
and the sources from which
it
Syphilis cannot be the

does not exist in more than
arises are questions still in doubt.

sole cause of paresis, as long as it
thirty-four to sixty-five per cent, of the cases.
Furthermore,
anatomically, is not a simple syphilitic process.

the
late manifestations of syphilis arise within a comAgain
paratively short time after primary symptoms, while paresis
paresis,
does not develop until ten or more years have elapsed after
the initial lesion. Taking into consideration all of these
facts,
the only acceptable view
is
that in a considerable
number
of cases syphilis somehow produces a profound change

which in turn gives rise to a toxin, which secondmetabolism
of
ary product is the direct cause of the pathological changes char-
Other apparent etiological

factors, as, alcohol, head injury, lead, and excesses, may bear
a similar causal relation to this disturbance of metabolism.
acteristic of
dementia paralytica.
The pathological changes here

enumerated can, as a whole, be regarded as pathognomic of
this disease.
Hyperostoses and exostoses of the cranium
with, but more especially without, thickening of the tables,
are occasionally present. The dura is usually adherent to
the
1
calvarium
in
Nissl, Monatsschr.
places.
Pachymeningitis
interna
and
f. Psy., IV, 413

Allgem. Zeitschr. f Psy., LX,
Nacke, ebenda, LVII, 619.
Cramer, Handbuch der pathol.
Anatomie des Nervensystems von Flatau-Jacobsohn-Minor, 1470, 1903.
215.
DEMENTIA PARALYTICA
hematoma
are
common.
The
false
membrane
281
is
almost
always situated on the vertex over the frontal, parietal, or
temporal lobes, and is of varying thickness, from a thin,

almost imperceptible rust-colored membrane, to a thick,
firm, white
absorbed
membrane, with small or
large, fresh or partially
clots.
The pia is thickened, whitish, and translucent along the

vessels, and especially over the vertex of the frontal and
parietal lobes and the first three temporal convolutions, and
rarely over the occipital lobes. The internal surfaces of the
frontal poles are often adherent. The leptomeningitis is
always more intense over the poles of the frontal lobes.
The Pacchionian granulations are usually increased in size.
The pia over the atrophied convolutions and broadened
The confissures often contains blebs filled with serum.
volutions are atrophied, especially in the frontal lobes.
In
these portions the cortex is narrow and often strongly

adherent to the pia, tearing upon its removal. In the other
portions of the cortex, and in the basal ganglia, the atrophy
is
much
less
marked.
The
ventricles are dilated,
and the
choroid plexuses may contain many cysts. The ependyma

especially of the fourth ventricle, and the inner walls of the
t
which give the usual

surfaces
a
frosted
glistening
appearance. These granulations are composed of an increase of neuroglia, which in
lateral ventricles, present granulations,
many
cases
undergone
^has
hyaline
degeneration.
The
some
weight of the brain is regularly below normal, and in

cases of long duration may be reduced to nine hundred
grammes.
The average weight
to thirteen
hundred grammes.
1
Microscopically,
1
nerve
cell
is
eleven hundred
and
sixty
changes of varying intensity
Binswanger, Die Pathologische Histologie der GrosshirnrindenErkrankungen bei der allgemeinen progressive!! Paralyse, 1893. Nissl,
282
None
are found in the cortex.

for paresis.
pathognomonic
of these cell changes are
Many,
especially the acute alter-
ation (see Plate 4, Figure 2), apparently represent a destructive process, while in others, as, for instance, the chronic
change
cell
sclerosis
Plate
(see
4,
Figure
5),
the
cell
may persist for some time. Furthermore, in cells giving

evidence of sclerosis, there may also appear evidences of a
superimposed acute change.
The
grave alteration (see Plate

4, Figure 3) apparently leads to absolute destruction of the
cell.
Undoubtedly also the acute and the chronic changes
can terminate in a destruction of the
cell.
Of
all
the
cell
changes only the acute alteration involves uniformly the

entire cortex.
Both the extent and the intensity of the
destructive processes are apt to vary. There is least involvement of the occipital lobe, especially in the calcarine
area,
and
central.
of the central convolutions, particularly the preFurthermore, in a disease area, normal cells may
be found lying side by side with altered cells. In all cases

there is involvement of the greater portion of the cortex, but
only in the severe or prolonged cases are all of the cortical
cells diseased.
The nerve fibres in the cortex and corona
suffer
atrophy in proportion to the extent of the degenera-
tion in the cortical neurones.
Where the
clinical course
has been prolonged and the neurones are much degenerated

there remain but a very few normal fibres. Similar destruction of the nerve fibres
may be found in senile dementia
and
it is
epileptic insanity,
but
not as far advanced as in
As the
result of the degeneration of the nerve cells
their processes, there
extreme cases
may
is
an atrophy
shrink to one-half
Archiv f. Psy., Bd. 28, S. 989.

Bd. 53, S. 172.
and
which in
normal width.
of the cortex,
its
Heilbronner, Allgem. Zeitschr.
f.
Psy.,
FIG. 3
FIG. 2
FIG. 1
FIG. 6
Acute alteration in dementia paralarge pyramidal cell. Fig. 2

Plasma cells
Grave alteration in dementia paralytica. Fig. 4
Fig. 3
crowded about a vessel in dementia paralytica. Fig. 5 Chronic cell change in
Fig. 1
Normal
lytica.
Fig. G
Rod-shaped
cell in
DEMENTIA PARALYTICA
This degeneration
The remaining
283
may be more marked about
the vessels.
are no longer arranged uniformly, but

are turned in all directions, either closely pressed together,
as seen in Figure 3, Plate 5, or surrounded by areas comcells
posed only of sclerotic tissue and vessels with thickened

Figure 3 should be compared with the normal cortex
walls.
as represented in Figure
2.
characteristic of paresis.
The
may
This anatomical picture is most

cell changes already described
be found in other conditions, but in none do
all
the
elements of the cortex suffer to such a profound degree as

here.
In senile dementia, idiocy, and even in dementia
prsecox,
many
cells
and
fibres are destroyed,
but the general
conformation of the remaining elements is undisturbed.

This distortion with the presence of scar tissue is present to
a recognizable extent in dementia paralytica, even when the
process is not far advanced.
In the areas of degeneration there may be a considerable
increase in the neuroglia tissue, in which spider cells take a
prominent part, appearing especially in the deeper cell

This great
layers of the cortex and about blood vessels.
increase of spider cells may be seen in Figures 5 and 6,
Plate 5, in comparison with Figure 4, which represents the
neuroglia present in the normal cortex. The increase in
neuroglia does not necessarily correspond to the destruction

of nerve cells, as normal nerve cells are often surrounded
by considerable
areas
all
on the other hand, in some

have disappeared without an
neuroglia, and,
the nerve
cells
may
appreciable increase of the neuroglia.

Vascular lesions in the cortex form a prominent part in
the microscopical picture. The vessels are increased in
number and their walls thickened, as may be seen in Plate 5,

Figure 3. Some of the vessels are dilated, a few totally
obliterated, and others show small aneurisms; but the
284
characteristic feature of this vascular change
tion of the perilymph spaces with ordinary
is
the
lymph
infiltra-
cells
and
particularly plasma cells (see Plate 4, Figure 4), the latter of

which may be regarded as distinctive of paresis, since they are
Furthermore, the
rarely found in other disease processes.
in
definite
rather
stands
of
these
cells
relationship
prevalence
to the extent of the disease process.
in the acute stages of the disease
Another form of
cell,
They are most prevalent

and later may disappear.
distinctive of paresis,
is
the rod-shaped
Figure 6). The cell

is long and narrow, sometimes curved, with a clear nucleus
and one or more nucleoli. These cells are found in large
cell first
described by Nissl (see Plate
4,
in proximity to blood vessels and lying

to
the
parallel
long axis of the large nerve cells.
In addition to the finer microscopic changes in the cortex,
one occasionally finds small areas of softening, which are
numbers mostly
discernible
by the readiness with which
either the superficial
layers of the cortex or the entire cortex are detached
from
Gross focal lesions, such as one might

accompany paralytic attacks, are rarely en-
the white matter.

to
expect
countered.
others
On the other hand, Lissauer, Starlinger, and

have pointed out that in the cases with circum-
scribed paralyses, hemianopsia, word blindness, and aphasia

there really are present corresponding definite circumscribed disease areas in the cortex with recognizable
secondary degeneration in the corona, basal ganglia, pons,
and cord.
The basal
and cerebellum also

present degeneration of the nerve cells and fibre tracts.
Weigert has demonstrated an increase of neuroglia in the
ganglia, central gray matter,
granular layer of the cerebellum, with a destruction of the

Purkinje cells and their processes. The cranial nerve nuclei
1
Starlinger, Monatsschr.
f.
Psy., VII, 1; Storch, ebenda, IX, 401.
MU
^-lSlill
1
:--'". .V
..'";*.*-o,
.'V -;;'
V-.V
;.>:-. -V.a?--"
,v r
FIG. 1
FIG. G
FIG. 4
Normal cerebral cortex. Fig. 3 CereCerebral cortex in idiocy. Fig. 2

Fig. 1
Glia in normal cerebral cortex.
bral cortex in dementia paralytica.
Fig. 4
Glosis with presence of spider cells in cortex in dementia paralytica.
Fig. 5
Showing the relation of spider cells with vessel walls in deep layers of
Fig. (5
cerebral cortex in dementia paralytica.
DEMENTIA PARALYTICA
of the medulla
show
285
similar changes to those seen in the
cortical cells.
The
is involved to a greater or less extent in

the
most important lesion being degeneraalmost
tion of the fibre tracts in the posterior and lateral columns.
spinal cord
all cases,
Degenerative changes are occasionally found in the peIn the internal organs vascular changes
ripheral nerves.
are so frequently found that they seem to bear a definite
Of these, atheroma of
relationship to the disease process.
the aorta and arteritis of the vessels of the liver and kidneys
are the most prominent.
Symptomatology.
From
the onset of the disease there
is
increasing difficulty of apprehension of external impressions.

Patients are unable to grasp clearly and sharply the char-
acter of the environment.
Later they mistake persons, fail

and overlook im-
to recognize former well-known objects,
portant details. Attention is maintained with effort. Long

and complicated sentences are not comprehended, and they
often miss the connection of things. Customary duties are
performed with difficulty and often incorrectly. Thus, there
develops a clouding of consciousness; the patients live a dreamy
existence, as if constantly under the influence of liquor.
an important diagnostic sign. Later

the disorientation increases. The patients may answer questions quite correctly and upon superficial examination seem to
conduct themselves in accord with their environment ; but
at the same time they neither know where they are, with
whom they are speaking, nor the significance of what is
This condition of torpor
is
taking place about them. They fail to recognize the season

or the time of day. A patient may say that it is summer
1
Westphal, Allgem. Zeitschr. f. Psy., Bd. 20-21. Westphal, Archiv

H. I., Bd. 12. Westphal, Virchow's Archiv, Bd. 39. Fuestner,
Archiv f. Psy., Bd. 24. 1.
f.
Psy.,
286
while leaning
upon a hot radiator and looking out upon a
snow-covered landscape.
This condition
of absolute disorientation,
when
finally reaches
one
the patients cannot perceive
any external impressions.

At the onset of the disease there is usually an increase of
The patients tire easily at their acthe sense of fatigue.
customed duties and require more frequent and longer
Hallucinations play an unimportant part.
periods of rest.
In the greater number of cases none appear, but in some
cases there exist for some time very many hallucinations of
or elaborate
all senses.
Again the
be very like that

Hallucinations of sight
clinical picture
of the acute alcoholic hallucinosis.
may
Hallucinaare often present in patients with optic atrophy.

tions of touch in connection with delusions of influence are
not infrequent.
The
memory are very characteristic and are

most
the
prominent of the mental symptoms. The
among
at
first
becomes defective for recent and passing
memory
defects of
events.
This defect
the patients,
for
correcting
more
is
sometimes keenly appreciated by

of and sometimes devise means
who complain
defective.
it.
Later,
memory becomes
The memory
is
progressively
especially defective in the
temporal arrangement of experience, and the patients fail

to recall the time of the occurrence of events. They cannot
inform you when the mail arrived, when they had breakfast,
or when they last saw you. These patients may live so
completely in the present moment that they may ask several
times a day where they are, how long they have been there,
or if they have ever seen you before. The early events of
are comparatively well retained for some time, the
patients being able to tell of their occupation, former places
life
of residence,
memory
and events
of their childhood.
also suffers late in the disease,
This remote
and here
also the
DEMENTIA PARALYTICA
time element
is
the
births of children,
first
to be affected.
287
Dates of marriage,
and important events are completely
for-
Finally they are unable to recall the place of birth

of their parents and children.
Lapses
gotten.
and even the names

memory, when
of
forgotten,
form
may
definite periods of time are completely

occur following epileptiform or apoplecti-
seizures.
The
store of ideas
undergoes a progressive impoverishment,

mental
terminating in a complete destruction of all the
The rapidity of this process varies with the

possessions.
of
the
disease and the power of resistance as well
intensity
as the intelligence of the individual. The more intelligent
resist longer, and the most frequented paths of thought are
retained longest. As memory fails, its place in the intellectual
often
life is
reminiscences
made good by
disappear,
the imagination. As real

invention runs riot. Whatever
mind is related as genuine; stories, or what may

have been told them by another, become a part of their own
experience. The patient relates that he was in a terrible
enters the
railroad accident last night, in which a dozen were killed;
he led the troops at San Juan; yesterday he had a conference

with the British ambassador. He has captured a hundred
beautiful women from a Turkish harem, and discovered a
new and
inexpensive motive power for automobiles. These

dreamlike fabrications are most pronounced in cases of
optic atrophy.
Very often such fabrications are used in
the gaps in recent memory. They can be brought
out and influenced by suggestion on the part of the listener.
filling in
The
patient may be somewhat dubious at first when expressthese

absurd reminiscences, but at the next interview
ing
all
doubt
memory
have disappeared.
external influences
will
to
susceptibility
of
This susceptibility of the

a part of the general
is
thought of the patients.
Their ideas
288
are never firmly grounded,
and
fail
to exert a lasting influ-
ence upon their thoughts and actions. Any accidental

impulse suffices to distract and lead them into another
channel.
Impairment of judgment is another very prominent symptom. It may be the first to call attention to the disease.
business
life
a success are
unity and system.

senseless
and
now
to arouse comment.
have made their
which
principles
Objects of former criticism
The former conservative
fail
lost sight of,
Weighty
and new plans lack

and
obstacles are overlooked
schemes produced with perfect serenity.
Business
standards are completely disregarded. Their

conceptions have no bearing upon the environment, but
center almost entirely about themselves, so that they come
social
to live in a sort of
own
dream world, in which everything depends

and wishes. The formation of delu-
ideas
upon
their
sions,
which partially
varies
much
results
from
in different cases.
this defect of judgment,

In some there are but few
delusions, but in most cases the delusions form a prominent

feature in the early stages of the disease. These delusions
are transitory, unstable, without system, and show confusion
and incoherence. They are characterized by vagaries, senseIt only

lessness, numerous variations, and contradictions.
rarely
stable
happens that for short periods the delusions are

and uniform like those of paranoia.
not unusual at the onset for the patients to express

some insight into their mental disease, complaining of their
It is
failing
memory,
irritability,
and increasing
difficulty of
Later, with increasing deterioration, all genuine

The patients then usually exhibit a feelinsight disappears.
thought.
ing of well-being; they claim that they never felt stronger

or more vigorous mentally. At times during the course of
the disease the patients
may make various hypochondriacal
DEMENTIA PARALYTICA
289
complaints, but even then they fail to recognize the real

physical symptoms of the disease.
The emotional
shows a profound disturbance.
life
At
The patients are

is usually increased irritability.
and
are
home
at
disturbed
sullen, peevish, and
work,
easily
apt to show considerable passion at trifling annoyances, and
first
there
may
they
On
the other hand,

show an unusual insensibility to the claims
completely lose control of themselves.
of others, indicative of the deterioration of the finer feelings.
They then
fail
to
show sympathy at the
suffering of their
children, are indifferent to immoral surroundings, and do

not take their wonted pleasure in reading or professional
pursuits.
The emotional
attitude
is
much
in accord with the char-
elated with expansive, or dejected

with depressing delusions. Later the emotional tone becomes very unstable, and there are frequent and abrupt
acter of the delusions;
it is
In the midst of laughter they
changes.
a storm of
tears, or misery
These changes of emotion
may
may
give
way
may break
out in
to silly happiness.
be brought by simple sugor

or
gestions
by raising
lowering the tone of voice, or even
by the expression
of the face.
patient lying on the floor,

his organs, that he had no
complaining that he had lost all

blood and could not breathe, when tickled in the ribs and
asked
how he
feeling fine;
felt,
come
"
I am
exclaimed, beginning to laugh,
and see me again/' In the demented
forms of the disease, where there may be only a few delusions, no especial emotions are shown, the patients being in
a condition of simple joy or irritable dissatisfaction most of
the time.
There
stability
sive
is
a profound change
and independence
weakness of the
will
of disposition;
of action give
power.
The
way
patients
the former
to progres-
become very
290
tractable,
but occasionally
may
be extremely stubborn.
Early in the disease they are led to indulge in all sorts of

excesses and sometimes persuaded to deed away property.
When
angered and determined to commit an assault upon

some one, they may be easily influenced to desist by a simple
window
patient about to leap from a third-story

because of fear, was readily prevented by the sug-
suggestion.
would be better to go down and jump up.

Any impulse that arises may be acted upon without refer-
gestion that
it
accomplishment. One
patient is said to have stepped out from a second-story
window for the purpose of picking up a cigar stump.
ence to the extreme difficulty of
of
its
In conduct, the patients show a disregard for the demands

custom and law, are unconstrained, and often commit
grave offences into which they have no insight. As a reason

for such conduct, they often say that they acted so because
happened to come into their minds. The social restraints normally imposed upon one by the environment
it
never interfere with the carrying out of their wishes.

are quite reckless of personal safety,
and occasionally
They
injure
themselves severely in their foolhardy actions. In conditions of great clouding of consciousness or in advanced
deterioration there are sometimes present some symptoms
characteristic of the catatonic form of dementia prsecox,
such as catalepsy, verbigeration, negativism, and stereotyped movements; but these are transitory and change
more readily and frequently than in catatonia.
Physical Symptoms.
The
physical signs of the disease,
motor and the sensory fields, are as extensive

and profound as the psychical. These may appear either
before the mental symptoms or not until dementia has
become well advanced; usually they are coincident.
Of the sensory symptoms, headache is often the first to
in both the
DEMENTIA PARALYTICA
291
appear, accompanied by a feeling of pressure as if the head

were being held in a vice, together with ringing in the ears
and dizziness. The special senses at first give evidence of
excitation,
which
later subsides into a state of insensibility
corresponding closely in degree to the stage of deterioration.

Some patients have difficulty in the recognition and localization of objects held before them, which by Fuerstner is
ascribed to involvement of the occipital cortex. Word
blindness and asymbolism are often observed. Hemia-
nopsia occasionally follows apoplectiform or epileptiform

Optic atrophy is found in five to twelve per cent,
attacks.
of the cases.
Disturbances of the senses of taste and smell
have also been observed by some, especially the

sense of taste for saline solutions.
cutaneous sensations
is
loss of the
The disturbance
quite often prominent; at
of the
first
there
uncomfortable sensations, burning or

drawing sensations, rheumatic pains, etc. Hence, many
patients are for a long time regarded as neurastheniacs. In
may be
all sorts of
an increased sensitiveness to cold. Later

analgesia appears, which may be so pronounced that needles
some
cases there
is
through a limb without pain.

Finally, the patients may pull out their hair, disturb an
open wound, draw out their toe-nails, and persist in mangling
can be thrust
their
own
entirely
flesh.
Of the motor symptoms paralytic attacks, mostly epileptiform or apoplectiform, are very important, occurring in
from forty-six to sixty per cent, of cases. The attacks may
only of a transitory dizziness with
perhaps an inability to speak. Attacks of this sort are
often the first symptoms to call attention to the disease.
be very
light, consisting
Occasionally the attack consists of a suddenly developing
aphasia lasting several days, unaccompanied by paralysis.

In the epileptiform attacks, which may be either of the
292
Jacksonian or of the ordinary type, confusion or stupidity

may usher in the attacks, which begin with a fall to the
loss
floor,
in
consciousness, and convulsive movements,

one limb, extending gradually to the others.
of
usually
Clonic movements predominate and are often synchronous
with the pulse. Convulsive movements may be confined to
a single group of muscles or to one limb. The duration of

the attack is from one to several hours, but sometimes
clonic
movements
more limbs
cus,
of varying intensity continue in
for days.
one or
condition similar to status epilepti-
where there are from twenty to one hundred attacks
persist for days, often terminating in death.

the
attacks the temperature is often febrile, the
During
urine frequently contains albumen, and there may be retendaily,
may
and feces, as well as paralysis of the muscles of

The fatal termination is usually due to aspiradeglutition.
tion pneumonia. The attacks pass off slowly, sometimes
tion of urine
leaving the patients in a condition of confusion. In the

earlier stages of the psychosis, these attacks leave the
more profound deterioration, and

sometimes also with signs of transient aphasia, hemiplegia,
patients in a condition of
hemianopsia, convulsive movements, or areas of anaesthesia.

Apopkctiform attacks often occur, and may be the first
important sign of the disease.
In these attacks there
is
the usual loss of consciousness and stertorous breathing,

with occasional high elevation of temperature, accompanied
by hemiplegia and aphasia.

loss
of
consciousness,
transitory paralysis.
similarly appear;
defects of vision.
In some attacks there
is
no
simply the sudden appearance of

Transitory sensory disturbances can
as, severe
paraesthesias, anaesthesias, or
It is a distinguishing feature of these
apoplectiform attacks that the paralysis disappears quickly

and without evident residuals. Other somewhat similar
DEMENTIA PARALYTICA
293
attacks, occurring in the course of the disease, are those in

which there is a sudden development of extreme confusion,
with motor restlessness,
difficult speech, flushing of
the face
and body, vomiting, and high temperature. These last from

a few hours to a few days and pass away quickly, leaving the
patient in his former state.
The frequency of the apoplectiform and epileptifonn
attacks depends somewhat upon the character of the treat-
ment.
cesses
They may result from emotional disturbances, exin eating, and especially from an accumulation of feces
hi the rectum, but they frequently
appear without evident
Bed treatment, regularly, reduces then- frequency.

occur
most often hi the demented form of the disease.
They
Motor disturbances of the eye include transitory paralysis
cause.
of single muscles (eighteen per cent, of the cases) and rarely

complete ophthalmoplegia. Differences of the pupil occur
about fifty-seven to eighty-three per cent, of the

immobile pupils in from thirty-four to sixty-eight per
in
and
sluggish reaction to light hi thirty-five
and
cases,
cent.,
five-tenths
per cent. (Argyll-Robertson pupil).
The musdes of the face lose their tone, the nasolabial fold
and other lines of expression disappear, and the countenance
becomes expressionless. This washed-out, expressionless
character of the countenance
well represented by the

group of three paretics seen hi Plate 6. Lack of tone in the
muscular system is also seen in their slouching and inelastic
attitude.
There
giving rise to
mouth or
is
is
also a loss of control of the muscles,
incoodination, noticeable mostly
eyes are forcibly opened.
fine
when the
tremor of these
almost always present. The voice loses its characteristic tone and becomes monotonous.
Tremor of the
muscles
is
either finely fibrillary or coarse and

a constant sign. In advanced cases there is
tongue, which
retractive, is
may be
294
often a rolling of the tongue about the mouth as if it were a

quid. This in some cases has been explained by the presence
mucous membrane. Gritting

associated with these movements
of areas of anaesthesia in the

of the teeth
is
occasionally
may be present alone.

Disturbances of speech are among the most characteristic
of the tongue, or
They are
either aphasic or articulatory.

often
Transitory aphasia
appears after paralytic attacks.
Paraphasia, which may appear at the same time, is more per-
symptoms.
and sometimes lasts several months. Word blindness

and word deafness are rarely encountered. There is occasistent
sionally
agrammatism, as seen
in the misuse of infinitives
and omission
of conjunctions.
There may be an elision of
in
as
the
use
of
syllables,
elexity for electricity, or a reduplication of syllables, as electricicity, and finally there may
be tendency to repeat
syllables,
forming a genuine word
clonus, as Massachusetts-etts-etts-etts.
Disturbances of articulation are more frequent. They

may follow paralytic attacks, but more often occur in-
dependently of them.
As the
result of difficulty in
move-
ment of the lips and tongue frequent pauses are made

between syllables or words
and when
hesitating speech
accompanied by a fall in the tone of voice produce a scanning
speech.
Gliding over the poorly articulated sounds gives
rise to an indistinct and slurring speech.
These difficulties
lead to the substitution of words or syllables similar in
sound but more easily pronounced, or to the elision of difficult syllables.
Many
patients, in their efforts to
overcome
these difficulties, stutter and produce an explosive speech.

patients often appreciate the difficulties of speech, but
The
are ready to explain them by dryness of the mouth or loss

of teeth.
Speech disturbances are readily observed in
ordinary conversation. The test words and phrases, if used,
DEMENTIA PARALYTICA
295
should be introduced into long sentences, because, if the

is concentrated upon single words, they may be
pronounced correctly. Words and phrases used for this
attention
purpose are: electricity, national intelligency, methodist

episcopal, ninth riding Massachusetts artillery brigade, etc.
The
central
and ataxic speech disturbances are best
by asking the patients to read aloud. Writing

usually shows defects similar to those noticed in speech, but
they are proportionately more prominent (Plates 7 and 8).
Patients, on the other hand, who speak clearly may produce
on paper an unintelligible muddle of words and syllables.
In advanced cases there is complete agraphia (Plate 7, Figures 2 and 3). The patients are then able to make but a few
unintelligible marks, and may even give up without making
elicited
sign.
The handwriting
is
characterized
by
irregularities
caused by the tremor, excessive pressure on the pen, and

carelessness.
The irregularities are more extensive than in
the case of the senile, whose lines
regular tremor.
Ataxia appears
first
show the
of all in those finer
as are employed by skilled workmen.
effect of
fine
movements such
Later the more
movements in locomotion, such as turning about

quickly, become ataxic. The clothing cannot be readily
buttoned, the gait becomes unsteady, swaying and shuffling.
delicate
In from sixteen to twenty-four per cent, of the cases of

paresis there are tabetic signs; such as, loss of reflexes,
ataxia,
Romberg
sign, paralysis of the
rectum and bladder,
and occasionally
girdle symptoms, lancinating pains, and

crises.
In from six to eight per cent, of cases, genuine tabes
antedates for several years the appearance of the paretic
symptoms (ascending
1
1
paresis or tabo-paresis).
In about
Cotton, Amer. Jour, of Insanity, Vol. 61, p. 581. Gaupp, Uber

Symptome der progressiven Paralyse, 1898. Torkel, Besteht
die spinalen
296
fourteen per cent, of the cases of paresis there are evidences

of involvement of the lateral column of the cord, as shown
by the spastic paralyses. In many cases spastic and tabetic

symptoms are variously combined. Intention tremor may
be present, and in a few cases choreiform movements are
marked enough to simulate Huntingdon's chorea. Later in
the course of the disease the patients become bedridden
and often develop contractures and muscular atrophy. The
body also tends to assume a curved position with a fixed tension of the muscles of the neck so that the head is thrown
forward and the body does not rest upon the bed throughout
its
entire length.
During
this stage of
the disease
is occasionally noticed convulsive movements of the

individual muscle groups, especially during active and pas-
there
sive
movements, but also when the muscles are at
rest.
1
The
pressure of the spinal fluid, according to Schaefer,

is increased in two-thirds of the cases from normal (40 to
70 millimetres) to 150-380 millimetres.
Furthermore, he
albumen is increased and contains serum albumin, while the normal fluid contains only globulin. The
microscopical examination of fluid shows a lymphocytosis
finds that the
(see p. 103).
The tendon
reflexes are usually exaggerated,
sometimes so markedly that the entire body shakes when the

tendon is struck. Frequently the exaggeration diminishes,
and
twenty to thirty per cent, of the advanced cases the

reflexes are lost.
In eighteen per cent, of the cases there is
in
a difference in the two sides.

is
The
loss of the patellar reflexes
usually associated with immobile pupils and myosis. The

is often elicited in connection with spastic
Babinski reflex
eine gesetzmassige Verschiedenheit in Verlaufsart und Dauer d. progressiven Paralyse nach d. Charakter d. begleitenden Rmaffektion ? Diss.,
Marburg, 1903.
1
Schaefer, Allgem. Zeitschr.
f.
Psy.,
LIX,
84.
ft
FIG.
Fia. 2
PLATE
Fig. 1 shows, besides the excessive pressure elision, substitution of letters and syllables.
The patient has attempted to write from dictation, " Around the rugged
rock the ragged rascal ran."
Figs. 2
and 3 represent conditions which approach complete agraphia,

down.
patients, after an attempt to write, simply laid the pen
in
which the
DEMENTIA PARALYTICA
symptoms.
The
electrical irritability of the
297
muscles
is in-
Disturbances of the
first, but later diminished.
bladder are often present, both retention and incontinence,
creased at
the latter usually being the result of the former. Sluggishness of the bowels may extend to obstinate constipation.
Finally in the end stages there is paralysis of both sphincters.
The sexual power may be increased at the onset, but later
The vasomotor disturbances consist of
it is diminished.
erythema, persistent blushing of the skin, rush of blood to

the head, dermographia, and cyanosis. The so-called trophic
changes, acute decubitus, increased fragility of the ribs,
and othematoma, stand in close relation to the vasomotor

changes, and are of frequent occurrence. Furthermore,
there is a loss of vitality and of the power of repair in all
tissues, so that a very trifling injury may lead to an extensive
lesion.
Acute decubitus once started
is difficult
to heal.
The
temperature during the course of the disease is mostly

normal, except toward the end, when it is apt to be sub-
normal.
striking peculiarity
is
the excessive elevation of
trifling disturbances, such as mild bronof the bladder, or obstinate constipaoverdistention

chitis,
There is often a rise of temperature during paralytic
tion.
temperature with
as already mentioned, there may be

short periods of a few hours or more of an excessively high
temperature apparently without adequate cause.
attacks,
and
finally,
The sleep is usually somewhat disturbed during the first

stage and more so during the second, where there is motor
excitement, but in the last stage the patients are sluggish
and may sleep much of the time. This varies, however, as
in
some
cases the patients
may, from the onset, show a
tendency to sleep continually, while in other cases insomnia

The appetite suffers
persists throughout the whole course.
at first and during excitement, but later the patients eat
298
The condition of nutrition is poor until excitement

subsides and deterioration is well advanced, when there is
well.
usually an increase in weight, which
may
last until death.
loss of appetite and impaired nutrition coexist,

to
extreme
emaciation. Occasionally albumen and
leading
l
sugar are present in the urine. The blood changes consist
Sometimes
moderate and progressive anaemia, in which the fall in

haemoglobin is most marked, a progressive increase of the
of a
polymorphoneuclear leucocytes reaching its highest point

during the terminal state, and a transitory leucocytosis
accompanying paralytic attacks. D'Abundo has called

2
attention to an increased toxicity of the blood, and Idelsohn
finds that the blood of paretics in a considerable proportion
of cases inhibits or prevents the
growth of cultures of
bacteria.
The mental and physical symptoms enumerated above

represent in general the clinical picture. The grouping of
the individual symptoms, however, varies widely in different
This has led to the recognition of four types of cases
cases.
:
the demented, expansive, agitated, and depressive, each of
which presents a somewhat different course from the onset.

The deviations from these types deter many from the
acceptance of this differentiation, but its value becomes
apparent in a considerable number of cases where one is
able to forecast the future duration of the disease
character of
many
of the
and the
symptoms.
The demented form, because of the simple deterioration,

unaccompanied by many delusions and hallucinations, its
rapid course without remissions, and the relative frequency
of its occurrence should be regarded as the type of the
1
Diefendorf, Amer. Jour. Med.

Amer. Jour. Med. Sc., 1897.
2
Tdelsohn, Archiv f . Psy.,
Sciences, Vol. 126, p. 1047.
XXXI,
640,
Capps,
^
TS -3
9 a
ii
DEMENTIA PARALYTICA
disease.
The
been and
still is,
disease, has in
until
it is
clinical picture of
299
megalomania, which has
by some, regarded as the prototype of the

recent years become less and less prominent,
now encountered
in less
than twenty-five per cent,
of cases.
DEMENTED FORM
The demented farm
is characterized
sive mental deterioration without
by gradually progres-
prominence of either hallucina-
psychomotor disturbance. Transitory

periods of delirious excitement, of anxious unrest with hypochondriacal ideas of depression, delusional states, or periods
tions, delusions, or great
megalomania may occur in this picture, but they are insignificant when compared with the rapid advance of profound deterioration.
The onset of this form is very gradual. The symptoms at
of
first
may
resemble those of neurasthenia; patients complain
of inability to apply themselves to work, loss of energy,

indefinite pains, feeling of pressure in the head,
and
irri-
tability.
They are forgetful and flighty, at times drowsy,
and at others somewhat confused. Soon mental deteriora-
becomes apparent in the inability to explain their

actions, in errors of judgment, failure of memory, and
absence of the usual moral feelings. Their work is irksome,
and they occasionally fall asleep over it. They forget to
tion
go to meals, make mistakes in
figures,
and overlook im-
portant matters. They are usually good-natured, tractable,

are easily led astray, and often drink to intoxication. In
some cases, however, they become obstinate and self-willed.

The household suffers, dinner is uncooked or improperly
Patients are
seasoned, and the children are neglected.
reckless and may even act in opposition to established preThe consciousness soon becomes clouded and the
cepts.
300
to thoroughly
comprehend their environment,

account of time, get confused as to place, and mistake
persons. They may even get confused in their own home
patients
fail
lose
and not recognize
friends
and
relatives.
Transitory hallucinations and delusions may appear, but

the latter are very weak, childish, arid easily influenced by
Occasionally there are weak attempts at fabrication.

During the early stages there may be some anxiety
with weeping and praying, and frequently also an increased
suggestion.
some sexual excitement,
irritability,
aggressiveness,
assaults; but the characteristic emotional change
is
and
a pro-
gressive deterioration of the feelings. The patients become

increasingly dull and apathetic. They are perfectly con-
tented wherever placed as long as the simplest needs are

satisfied; such as, food, drink, and tobacco.
They have a
complacent smile when addressed, greet strangers very

Often at first
cordially, and are friendly with every one.
is some insight when the patients complain of slowness of thought and failure of memory, but the increasing
deterioration obscures this feeble capacity.
On the other
there
hand, they
may
express a feeling of well-being
and
perfect
confidence in their business capacity.
The
capacity for work suffers soon. The patients become

careless in their duties, forget engagements, allow letters to
go unanswered, go to work at all hours, and finally stay

away altogether. A few patients may struggle along with
their work, realizing
and worrying over
difficulties
and
fre-
quent errors, while others neglect their occupation to look

after all sorts of unnecessary and unprofitable affairs. They
may become
restless,
in excesses or
wandering aimlessly about, indulging
committing petty crimes.
They lack
will
power, are easily led astray, are unable to care for themselves, forget when to go to meals, and neglect their per-
DEMENTIA PARALYTICA
On
sonal appearance.
inaccessible, repulsive,
301
the contrary, some patients are

surly, answering questions as
and
if angry, rebuffing friendly advances, and opposing without

reason anything desired of them.
A few patients,
in spite of
an advanced stage of
They greet one
tion, present a good demeanor.
deterioracorrectly,
and appear perfectly at ease in talking about themselves,

but at the same time are disoriented, and are unable to give
any coherent account of their lives. The patients usually
enjoy a good appetite, sleep well, and are the picture of
The mental deterioration may have been so gradual
health.
and so unobtrusive that the friends and relatives fail to
appreciate the profound degree of deterioration exhibited.
This form of dementia paralytica embraces forty per cent,

of the cases admitted to institutions.
Paralytic attacks
occur in almost one-half of the cases.
frequent than
Remissions are
less
The duration in almost

does not extend beyond two years. In
in the other forms.
half of the cases
eighteen per cent, of the cases death ensues within the

year, and it is very rare that the disease lasts five years.
first
EXPANSIVE FORM
The expansive form

of
is characterized
expansive delusions, a
prolonged
by great prominence
course,
and
greater
prevalence of remissions.
The onset is usually gradual, with change of character,
difficulty of mental application, signs of failing memory and
judgment,
physical
increased
signs
irritability,
as fainting
turbances, syncopal attacks,

the onset is quite sudden.
spells,
and, in
addition,
transitory speech
and headaches.
such
dis-
Occasionally
Following these prodromal symptoms, there
may
first
302
develop the picture of the depressed type with delusions of

persecution, self-accusation, and anxiety, but usually from
the onset there is a condition of excitement with elation,
which transitory states of

depression with weeping may occur. In case there have
been signs of despondency and illness, these then disappear
and grandiose
delusions, during
deand the patients gradually

occasionally suddenly
of
marked
a
are
feeling
well-being; they
velop
bright,
They busy themselves
affable, talkative, and energetic.
with new and elaborate schemes for getting wealthy, stake
out property, and draw designs for wonderful machines.
are busy from early morning to late at night, soliciting

patronage, ordering large quantities of material for building
They
and
at
The numerous expansive delusions

within the range of possibility and may appear
for other purposes.
first
are
attractive to the unsuspecting, but soon pass into the realm

of absurd imagination, reminding one very much of the
prattle of children.
These, with the restlessness, present
the characteristic picture of megalomania. The patients

claim never to have felt better in their lives, can lift tons,
can whip the best man on earth, have the strength of a

thousand horses, and can move a train.
They believe their English the best; they speak as fluently

several other languages; their voice is clear and distinct
and can be heard for many blocks, because of its excellent
qualities.
compose
inspiration to write a book; can

beautiful poems; can deliver an oration on any
They have the
associate only with the most cultured people;

only the genuine blue blood courses through their veins;
they are going to build a marble mansion at Newport, and
subject.
They
have a floating palace. Business is flourishing; they are

"
mint of money/' have several gangs of men
making a
for
them, and still there is more work than they
working
DEMENTIA PARALYTICA
303
can attend to; besides their regular business, chickens are

being raised by a special method at an enormous profit;
they have secured rich gold claims in Nevada, which are
doubling in wealth daily.
Formerly they were brakemen, but now run the fastest

finest train in the world from New York to Chicago
without a single stop, allowing none but millionnaires to ride;
and
besides a profitable law business, they are now engaged in

writing a novel which will startle the world, and for which
they have received priceless offers from publishers in this
country and in Europe.

ful
power
A ship carpenter developed wonder-
in his eyes, so that he could detect defective wood

by simply standing in the hold and looking out-
in a vessel
ward, and for this reason he was appointed detective of a

marine insurance company, and had travelled all over the
world inspecting vessels. He had become so wealthy that

all the banks in the state were in his possession.
A seamstress had devised a new method for cutting
dresses,
which had won her world-wide fame, having been
Europe because of her wonderful

She herself could cut and sew a hundred dresses
a day, and had under her five hundred girls, all of whom
used gold thread. She could sew on a thousand buttons a
called to all of the courts of
success.
minute. A jockey had discovered a new way of breeding

and training runners, and now from his Kentucky ranch
was supplying every circuit and handicap with winners.
The utter absurdities which increase from day to day are
proof of the increasing mental weakness. The delusions
abound in contradictions and become more incoherent, the
product of a more dreamy ingenuity. The patient now
drives the largest engine in the world, drawing a thousand
palace cars, all lined with gold and trimmed with pearls,
which encircles the globe every twenty-four hours, stopping
304
only at New York, San Francisco, Calcutta, Paris, and London. He now has formed a chicken trust to extend over the
whole earth, and
will reconstruct the social
system of the
be
world, so that only the Chinese
employed in hatching the eggs. Another has a most wonderful herd of cattle,
will
whose horns are forty feet high, whose eyes are diamonds,
whose feet are gold, and each cow produces five hundred
milk in twenty-four hours, the patient himself milking a thousand a day.
pails of
The
patients are the most beautiful beings that ever lived.
They have married seven hundred

thousand children,
dresses;
they can
all of
whom
millionnaires, have twenty

have gold slippers and gold
they themselves wear only diamond trimmings;

fly away in the air to a world where there is a
thousand miles long filled with lovely people who

do nothing but amuse themselves. They are not human,
but divine; can create a universe, visit all the stars, have
sent Christ to Mars; whatever they touch turns to gold.
castle ten
They know
all
sciences,
are the greatest physicians in
a hospital of marble twenty stories

existence;
high, provided with a bar for the doctors, where the choicest
wines and the best Havana cigars will be supplied; and there
will build
will be a dissecting room, with a huge ice box, where ten

thousand bodies can be kept all the time.
They
will build
a tunnel through the earth and bring all

One patient said that he was
the Chinamen here to work.
going to build towns; that he had been to Washington to

see the President, that he wanted six thousand billion gunboats, one million bomb-shell boats, one million marines, and
that he would cross the ocean and blow up all of the countries and bring the people out west and put them on farms;
that he would blow up the Queen's buildings, and that he
would give each one
of the marines
two bags, and each
DEMENTIA PARALYTICA
would have to go two times
and diamonds.
in order to bring
305
away the
silks
These delusions are almost entirely self-centered. They

may change rapidly, each day new and extravagant ideas
filled with the most glaring contrathe tendency to expansiveness is less
marked. Transitory hallucinations of sight and hearing are
occasionally expressed, but they never take a prominent
appearing, which are
In
dictions.
women
part in the disease picture.

Consciousness is somewhat clouded during the development of the megalomania. There is usually disorientation
for time, places,
and persons,
the patients are too
much
absorbed in their numerous ideas to note the surroundings

or to take account of time. Later they become acquainted
with the place and a few of the persons, but they rarely
know the month, day, or the year. The content of thought is
centered entirely about
self
and the many varied delusions.
At
first it is usually coherent, although at times, in connection with great psychomotor restlessness, there may be incoherence, distractibility, and sometimes flight of ideas.
The
patients are usually talkative, and may produce a continuous stream of delusions. Incoherence of thought is
more evident in
The emotional
their letters.
attitude corresponds closely to the content
of the delusions; the patients are cheerful, happy, hopeful,
contented,
and
exalted.
Everything in the environment
is
pleasing; they are in luxurious quarters, have the best of

food, plenty of servants, fine clothing, fast horses, and are
associated with the finest
men
in the world.
It often
happens that for a short time, a few moments or hours, rarely

days, they lose spirits and become depressed, complaining
of confinement, and expressing hypochondriacal delusions,
or
weep
bitterly because of harassing persecutions.
Even
306
when most miserable it is often possible by suggestions to

reestablish the feeling of well-being, showing the great instability of the
is
emotional condition.
always present, manifesting
itself
Increased irritability
upon the slightest
provocation. Disagreements or doubts relative to their

superiority or immense wealth may arouse anger or even an
Later in the course of the disease the

aggressive attack.
are
patients
usually in a uniform state of quiet cheerfulness
in spite of their bedridden condition with filthiness, paralysis,
and even
asked
"
contractures.
how he
feels,
The
paretic
on
his deathbed,
often drawls out with
when
some animation,
Fine, fine."
In the psychomotor field excitement predominates from

the onset and may reach an extreme degree. At first the
patients are restless, bustling about on new and important
business, remaining up until late at night, devising plans,
writing many letters, and travelling about from place to
place.
They are very
talkative
and make confidants
of
For short periods in the course of the

may develop extreme restlessness, with insomnia,
every one they meet.

disease they
complete clouding of consciousness, recklessness, aggressiveness, and impulsiveness.

They shout from fear, mutilate
their
own
obstacle.
bodies,
and rush about
blindly diving into
any
It is impossible to attract their attention or to
get coherent answers. They fight off imaginary enemies and

shout threats and curses. These conditions of excitement
rarely last longer
than a few hours or days, and disappear
gradually, usually leaving the patient in a state of

profound deterioration.
more
In actions the patients soon become foolish and show a

lack of judgment and moral obtuseness. They develop bad
habits, smoke or swear, enjoy telling obscene stories, seek
the
company
of lascivious
women, and become
disorderly in
DEMENTIA PARALYTICA
307
and careless in appearance. They may assault or

commit thefts, but every action shows an absence of plan,
When conrecklessness, and utter disregard for others.
dress
fronted with their observed behavior,
it is all
perfect serenity.
As the disease advances, the activity
production of unintelligible letters and
is
denied with
limited to the
plans, scribbling
on paper, and collecting useless rubbish. The patients are

happy and contented throughout it all, invariably asserting
with brightening countenance that they are feeling fine.
"
They may be heard mumbling to themselves,
millions,"
"
"
fine horses," "beautiful women,"
mansions,"
grand
mere relics of former ideas which now represent the last
traces of their intellectual
life.
The expansive form comprises from fifteen to sixteen per

cent, of the paretics.
The duration is more prolonged, less
than one-third of the cases dying within two years. Some
cases even live fourteen years.
Remissions occur in onethird of the cases, which in part accounts for the prolonged
course.
It sometimes happens that the expansive form
passes over into the depressive, and vice versa, and this may
take place several times, simulating the picture of manicdepressive insanity.
AGITATED FORM
The
agitated
form
is characterized
by a relatively sudden
onset with a condition of great psychomotor excitement
and
and
most extremely expansive delusions, great clouding of consciousness, and a short course. The
delirium,
the presence of the
usual prodromal symptoms are lacking and there rapidly

develops extreme megalomania.
change of disposition is
often noticed for a time previous to the sudden outbreak.
The
patients rapidly
become very
pronounced feeling of well-being.
energetic,
They
and express a
are born again,
308
and the strength of ten thousand men ;

could carry an ocean vessel or fly to the moon in a second.
They have acquired all knowledge, can educate a thousand
possess the ambition
men an hour,
teaching them to speak every known language.

They themselves are Gods, Gods over God, have created God
and the universe; have been everywhere from the heights
of heaven to the depths of hell. They are now establishing
a new method of reckoning time; by their decree the days
are to be one thousand hours long, the weeks are to
contain one thousand days, and the years ten thousand
They know how
and by a new
size and
The world moves and stands at
shall have a third eye.
are
interested in all wars and have
their command.
They
marshalled huge armies. Their wealth is fabulous, more
months.
formula
man
shall
to create animals,
be increased a hundred-fold in
than any one man ever possessed before. All quantities are
reckoned in the ten thousand billions; they own ten thouten thousand billion cows; ten thou-
sand
billion houses;
sand
billion acres of land, etc.
Italian marble, with gilded
Their houses are built of
domes
floors are of onyx, the furniture,
set
with diamonds, the
pure gold, and the hang-
ings, the finest fabric, trimmed with pearls and sapphires.

Their ideas become more and more expansive, and finally
seem even to surpass the bounds of imagination.

In the midst of these megalomanic delusions, one occasionally encounters the most extremely pessimistic ideas which
are sometimes hypochondriacal. The patients claim that
they are suffering untold misery from sharp pains in the
back; some one entered the room at night and disem-
bowelled them, so that the following morning they could

not go to stool; miles of fine electric wires have been placed
in the flesh, about the limbs
through which
and completely
filling
the skull,
electrical currents are nightly applied, causing
DEMENTIA PARALYTICA
be some insight into the failand the defective nutrition, which leads them
the flesh to burn.

ing
memory
309
There
may
momentarily to fear that they are suffering from cancer of

the most malignant type, but at the same time one is
assured that they are undergoing a process of purification
which will leave them healthier and mightier. Sometimes
they are perplexed at their own stupidity for allowing themselves to be confined in a hospital instead of going to
Europe
consummate a deal by which millions would have been
made. Hallucinations of sight and hearing may be present,
but are not prominent, and fail to influence greatly the
to
clinical picture.
The psychomotor
showing
condition is one of great restlessness,

The patients
occasional impulsive movements.
sing, laugh, shout, and prattle away like

innumerable plans and many pleastheir
over
children
ures.
They are constantly in motion, going from one thing
are
talkative,
to another, working in a planless way on various schemes,

scribbling unintelligible letters to millionnaire friends, issuing
to military staffs, and sending cablegrams to the
different crowned heads.
They have no care for themselves,
commands
neglect personal appearance, forget about eating, smear

their dresses or the walls with the food placed before them,
masturbate, and expose themselves indecently.
Thought is usually incoherent, and there is often observed

a flight of ideas. Emotionally, there is a marked irritability,
interference quickly leads to outbursts of passion, with
cursing, threats, and aggressiveness; but elation predomi-
and
Physically, the condition of nutrition suffers profoundly, and there is a great loss of weight, because of the
nates.
small
amount
of food ingested
and great
temperature may be subnormal.

A few cases of the agitated form
may
restlessness.
The
be characterized as
310
These cases present an extreme grade of

galloping paresis.
excitement and profound clouding of consciousness, leading
within a few weeks or months to fatal collapse. It sometimes
represents the end stage of the agitated form and occaThe patients are comsionally also of the depressed form.
unable
to
comprehend the surroundings
pletely confused,
or to respond to questions.
singing,
producing an
are noisy, shouting
They
unintelligible babble, with
repetitions of syllables or purely inarticulate sounds.
and
many
The
extreme, the patients being in constant motion,

the
bed or wall, forcing the legs up and down,
pounding
running about the room, slapping their hands, waltzing to
restlessness
and
is
and bruising themselves extensively by their reckless movements.

Insomnia is extreme and food is refused,
or if taken, cannot be retained, and the patients are wholly
unable to care for their personal needs. The weight falls
rapidly, the temperature becomes slightly elevated, and the
heart's action feeble and irregular.
Epileptiform and
are
Within
a few days or
attacks
apoplectiform
frequent.
fro,
weeks the restlessness subsides into a condition of stupor,

which the movements are uncertain and tremulous. The
in
temperature becomes elevated as the result of infection from

the various wounds or acute decubitus, the mouth is filled
with sordes;
and diarrhoea appear,
profuse perspiration
which with heart failure lead to death.

The agitated form represents about eleven per cent, of the
Remissions occur in one-fourth of the cases.
paretics.
Paralytic
attacks are
frequent.
than two-thirds of the cases
The duration
is less
in
more
than two years.
DEPRESSED FORM
This form is characterized by despondency and depressive delusions which prevail throughout the whole course of the disease.
DEMENTIA PARALYTICA
The
onset in this
form
insidious.
is
The
311
patients notice
memory, decreasing power of application,

weariness
upon exertion, and change of disposition.
greater
The persistent headaches, the numerous pains, and failing
their
failing
memory
lead
them
to consult one physician after another.
They worry about themselves and soon become hypochondriacal.

They claim that they are suffering from a complication of diseases and that they can never recover.
During
this stage they are not infrequently regarded as neuras-
theniacs, hypochondriacs, or hysterical patients.

But their hypochondriacal complaints sooner or later be-
come
They then complain that the
entirely senseless.
rotting away, the skull is

brain to shrink, the mouth
is
taste
up
is lost,
the throat
is
into the brain, the
scalp
filling in with bone, causing the

is filled
with
sores, the sense of
clogged up, so that the food passes
stomach
intestines are so paralyzed that
is melted away, and the

excrement has been accu-
mulating within them for many months, the kidneys have

been moved, so that water passes directly through their
bodies. They claim that they are dead, the blood has
ceased to circulate, and they have turned to stone. The
have dried up and their manhood has disappeared ;
"
"
a false passage has formed so that the vital fluid passes
testicles
out of the rectum.
In connection with these ideas they are
constantly fingering different parts of the body, especially

the face and sexual organs. They may sit for hours with
hands on their throat for fear feces will pass into the mouth,
or
may
abed as
moved.
lie
if
dead, claiming that they would
fall
apart if
Delusions of self-accusation are usually associated with
and occasionally predominate

The patients believe themselves
these hypochondriacal ideas

in the
clinical
picture.
great sinners, that they have committed the unpardonable
312
must
have stolen property, and injured

their children.
They have caused the death of a friend by
and
negligence,
every one knows that they are murderers.
They persist that they have always been impure and have
sin,
die
on the
cross,
A patient
moaned
months because he
had not provided his family with sufficient food and was
being held up to the whole world as an example and must
led
many
astray.
for
suffer the penalty of death.
Very often fear develops in

connection with these ideas of self-accusation, when the
patients are in terror because they are being constantly
watched, expecting at any moment to be imprisoned or
carried away to the scaffold; or they dread personal injury
and abuse.
Delusions of persecution are usually accompanied by hallucinations of hearing,
when they
suspect plots against their

lives and complain that their families, are being outraged.
They are being regarded as desperadoes on whose head there
is
a high price.
them
into exile.
crowd
of
men
The troops have been summoned to escort

They hear themselves slandered by a
outside, or overhear intrigues against them.
Others threaten them.
Hallucinations of the other senses
are infrequent.
The consciousness soon becomes
much
clouded.
There
is
considerable disorientation; friends are mistaken, and time

confused. Occurrences in the surroundings have reference
is
only to themselves. The bathing of others suggests to their

minds that they have polluted their fellow-patients, and the
preparation for the morning walk signifies that the whole
company are getting ready to attend their public prosecution.
At the table others are deprived of food on their
In this condition they develop great anxiety with

restlessness; pace back and forth in their rooms, moaning
account.
and groaning, sometimes uttering
single
expressions,
as
DEMENTIA PARALYTICA
"
"
death,"
313
destruction," pick at their finger-nails, pull out
and are unable to eat. Every unusual sound

them and causes them to shudder and shrink back
their hair,
frightens
farther into their rooms.
Finally they cannot be persuaded

huddled up at one side, with the
head buried in the clothing. In this condition they may
to leave the bed, but
lie
attempt suicide or mutilate their own bodies; one patient

tore through the anal sphincter into the vagina with her
hand.
Extreme anxiety with
restlessness does not exist very
long at a time, usually only for a few hours or at most a

few weeks. It may appear and disappear suddenly. In
the interval the patients are not as agitated but yet are
despondent and seclusive. The depressive delusions are retained but they show far less emotion. The mental depression is not always uniform, as one occasionally notices
emotional indifference, and even transitory periods with a
feeling of well-being
is
and
of elation.
When
deterioration
well advanced, expansive delusions occasionally appear.

More or less prolonged stuporous states appear at times
when the patients become

abed
in
one
mute, lying
position oblivious to the surroundings, refusing nourishment, and allowing the feces and urine
during the course of the disease,
to pass unheeded.
ignored.
Requests are carried out slowly or wholly

The patients appear indifferent, but at times they
display some emotion, or they may show some anxiety.

Hallucinations and illusions may be more or less prominent
or entirely wanting. Consciousness is usually clouded.
These states
months.
of
form
dementia
depressive
paralytica comprises
one-fourth of the cases, and appears rather late in life,
may
last several
The
mostly after forty years of age. Remissions occur in less

than twelve per cent, of the cases, while paralytic attacks
314
occur in twenty-five percent.

This type is one of the
severer forms, as over seventy per cent, die within two
years.
Course of dementia paralytica.

Dementia paralytica may
be divided into three stages: the stage of onset, the stage of
acute symptoms, and the terminal stage of dementia The lines
.
of division are very indefinite, as the first stage may very quickly
pass into the acute stage, when the symptoms remain in abeyance for a few years ; or the case may be one of apathetic deterioration from the onset, devoid of
indicative of definite stages.
be prolonged.
In
any prominent symptoms

The terminal stage is apt to
the patients are dull, stupid, apathetic,

entirely indifferent to their surroundings, unable to care for
themselves, or occasionally expressing incoherent fragments
it
of former delusions.
They sit unoccupied save for the taking

which they often have to be helped. The
physical symptoms in this stage advance to general paresis
of nourishment, to
of all of the muscles, necessitating confinement in bed.
Sensation is greatly impaired, muscular atrophy and weakness become marked, and finally contractures appear. In
the end patients become nothing more than vegetating
organisms.
The course
of the physical
symptoms by no
mental symptoms. On
means
the one hand, there are cases in which speech disturbances
and incoordination may antedate for a long time the apcorrespond to those of the
pearance of faulty memory or judgment, and on the other

hand, the mental symptoms may appear first.
The two important

paralytic attacks and
factors in the course of the disease are
remissions.
The attacks may appear
at any time during the course, producing an unexpected

progress in the deterioration or even a fatal termination.
in the disease, being followed by a condition
advanced deterioration, but more frequently occur during
They may usher

of
DEMENTIA PARALYTICA
315
the terminal stage. These attacks accompany chiefly the

demented and the expansive forms.
Remissions are most often encountered in the agitated and

expansive forms and very rarely in the demented forms. The
improvement, which
is
usually rapid, appears only during the

Both the physical and mental
earlier stages of the disease.
symptoms show marked improvement; the consciousness

becomes clear, the content of thought coherent, and the
delusions and hallucinations disappear. The patients often
look back upon their psychosis as a sort of dream, without
In the course of a month or two they may
clear insight.
have improved so much that, as far as the limited associations
When
of the institution permit, they appear perfectly well.
at liberty, however, it is apparent to their friends that they
have
lost their
former mental energy; they
are changed in disposition.
employment and disregard the advice

exercise care.
Some
and
tire easily,
Yet they are usually eager
for
of the physicians to
of the patients are able to engage
successfully in their former occupation and support their

In other cases the remission is only partial; the
families.
become clear and coherent, while the expansive

and depressive delusions disappear; but there still remains
patients
a tendency to excessive activity, with a desire to enter into

uncertain business ventures, to be lavish with money, carepersonal appearance, and irritable and fretful in disThe duration of the remission seldom lasts over
position.
less in
three or four months, but in
or
more
some
cases
it
extends over three
years.
Diagnosis.
be considerable
During the early stages of
paresis, there
may
difficulty in distinguishing acquired neuras-
thenia (see p. 153).
The
depressive form of paresis is distinguished from melanby the evidences of mental deterioration:
cholia of involution
316
weakness of judgment, moral instability, failure of memory,

defective time orientation, silliness and incoherence of the
and presence of physical signs. The melancholiac

a
shows
greater prominence of self-accusations and good
orientation, except in cases with many hallucinations and
delusions,
delusions.
The
intense apprehensiveness of the paretic
is
than that encountered in melancholia, and is

relieved
occasionally
by short periods of moderate but
distinct feeling of well-being.
The melancholiacs have
their good days, but they never show elation.
less persistent
The
depressive phases of manic-depressive insanity are distinguished by the absence of any signs of mental deteriora-
and by the presence of retardation among the motor

phenomena. In the stuporous states the manic-depressive
patient takes some notice of and partially apprehends his
surroundings, although he takes no part in them; he shows
some anxiety and discomfort when threatened with a needle
and seldom moves voluntarily and then slowly, while the
tion
is partially disoriented, does not react when threatened with a needle, and occasionally moves freely and even
paretic
and usually presents characteristic physical signs.

The manic phases of manic-depressive insanity are differentiated from the expansive and agitated forms of paresis
by the absence of mental deterioration. The paretic is unable to recall correctly recent events, and especially the date
of their occurrence.
His delusions are more extreme,
his emotional attitude is
fantastic, and contradictory;
and
the
variable,
dependent upon
surroundings and sugThe manic, on the other
gestions, and he is more pliable.
is
more
alert
in
and
hand,
quick
apprehending when his
attention can be attracted; he shows an accurate memory;
restlessly,
his delusions are less often contradictory, are expressed with

less
assurance and more facetiousness;
and he
is
seldom
DEMENTIA PARALYTICA
contented and
is less
pliable.
317
In conditions of extreme excite-
ment, the orientation and the coherence of thought

disturbed in paresis.
is
more
happens that periods of excitement at the onset

of the disease are mistaken for delirium tremens, especially
where early paretic symptoms have escaped notice in an
It often
alcoholic (see p. 183).
Dementia prcecox
by the absence
of the characteristic physical signs, good orientation, and
the presence of catatonic features (see p. 270). The sois
usually differentiated
symptoms, if they occur in paresis, are aca

companied by greater disturbance of memory and greater
insensibility and cloudiness than what one encounters in
called catatonic
dementia praecox. In case these distinguishing features

cannot be determined, on account of negativistic signs, then
one has to depend upon the presence or absence of physical
signs.
The presence
of simple difference of pupils, increased
moderate tremor, and, indeed, even attacks of dizziness and of an epileptiform nature, are not conclusive for
reflexes,
paresis.
If
a patient with such symptoms is uncertain and

is unable to orient himself
helpless in simple figuring tests,
as regards time and to readily recall early experiences, and is

easily influenced in action and feeling, provided it is not the
mechanical response to stimuli, then the condition is more

indicative of paresis.
The states of dementia in paresis lack
the tendency to adornment, the mannerisms, the occasional
exacerbations,
refusal of food.
and the
persistent stupor, negativism,
In the paretic excitement, there
may
and
occur
impulsive and stereotyped movements; but they are not

accompanied by the irrelevant and incoherent speech of the
catatonic, and furthermore, the excited paretic is not
oriented to the extent that the catatonic usually is. In the
paranoid forms there is neither the paretic inability to com-
318
prehend the surroundings nor the permanent feeling of wellbeing, hallucinations are much more frequent and expansive
delusions develop more slowly, while the paretic does not show
the delusions of influence so
common in
paranoid dementia.
The late
cases of dementia prsecox, in which despondency may

predominate, are distinguished by the susceptibility to ex-
commands, and by the impulsive
ternal influences, such as
restlessness or stupor with resistiveness.
diagnosis may
spinal fluid.
The
rest
Ultimately the
the
examination
of
the cerebroupon
differentiation of paresis
in those diseases in
is
apt to be most
which there are extensive
particularly cerebral syphilis
insanity (see p. 338),
and
(see p. 331),
senile dementia.
difficult
cortical lesions,
arteriosclerotic
Senile dementia
may be recognized by the age at onset, the more prolonged

course, comparative poverty of delusions, and absence of
characteristic
motor symptoms.
Cases of cerebral tumor occasionally present mental sympin the demented form of dementia
toms similar to those

paralytica.
focal
The
symptoms
chief point of differentiation, in case

exist,
is
no
the presence of the cupped optic
disk.
The prognosis of the disease is decidedly unPrognosis.

favorable.
Death occurs in the vast majority of cases within
two years; the length of life, however, varies in the different forms. A few cases survive five or six years. One case
of eighteen years' duration has been reported.
There are,
however, some cases of so-called arrested paresis Undoubtedly
not a few of these cases were never paresis at all, but rather
.
belonged to the group of organic psychoses characterized by

degenerative changes in the cortex, especially
syphilitic, which during life are differentiated only with
great difficulty. Again, there is a possibility that some of
extensive
DEMENTIA PARALYTICA
319
these cases represent a group of cases still undifferentiated,

which at the onset present the characteristic mental and
physical symptoms of paresis, but later subside into a
condition of dementia with possibly a few delusions and the
It cannot be positively
residuals of the former physical signs
stated that some of these are not paretic cases which fail to
.
run the usual
fatal course.
It is still
a mooted question
whether patients may not even recover from paresis. In the

first place, Tuczek reports a genuine case of paresis, confirmed by autopsy, with a remission of twenty years. Again,
Alzheimer has found in paretics, dying during a complete
When one
remission, the characteristic paretic lesions.
considers that these remissions often cannot be distinguished
from genuine
recoveries, except for the later recurrence of
the disease, it at once becomes apparent that a complete

subsidence of all mental symptoms may occur, which, extending through a series of years, encourages the belief that
recoveries are possible. The immediate causes of death
are paralytic attacks, pneumonia, and intercurrent diseases,
sometimes septicaemia following infection from wounds,

sometimes suffocation caused by food entering the air
passages; but the usual manner of death is from marasmus
failure.
The patients become emaciated, the
muscles atrophy, the heart weakens, the pulse becomes im-
and heart
perceptible,
and
Treatment.
tomatic.
life
gradually flickers out.
The treatment of the disease is mostly symp-
In cases where there
is
a history of probable
syphilitic infection the intensified mercurial treatment is

1
It consists
justified by the small number of reported cures.
intramuscular injection of mercuric salicylate in

albolene, beginning with J grain twice weekly and increasing
in the
Collins,
May
6,
Med. Record, Vol.
1905.
9, p.
125.
Dana, Jour. Amer. Med. Ass'n,
320
to 1 J grains, administered for six weeks, and then an interval

of six months during which general tonics are pushed.
Following this, another period of similar mercurial treatment. Some prefer the injection of bichloride of mercury,
J to J grain daily, given for six to eight weeks, repeated after
an interval of six months. All other specific methods of
treatment have fallen into disuse.
utmost importance that the patient be submitted

forced
to
rest, with removal from business and uncomfortable surroundings, and the establishment of a suitable
It is of
Quiet and
daily routine in the physical and mental life.
tractable patients in good circumstances may be treated at
home, but others usually require sanitarium or hospital

treatment. Suitable rest and relaxation cannot be procured
"
"
at the fashionable health resorts with the numerous
cures
and attractions.
Next to rest, there should be outlined a simple
nutritious
diet, including abstinence as regards alcohol, coffee, tea, and

A carefully planned daily routine, including extobacco.
ercise in the
open
air,
with gentle massage,
The
and
is
carefully executed hydrotherapy
of importance.
conditions of paretic excitement are best relieved
by
the bed treatment and the use of the prolonged warm baths
1
At the first application of the bath, it may be
(see p. 140).
1
Where the warm bath
is inaccessible, the cold packs may be substihands of several American physicians seem to give
excellent results. The packs to be effective must be properly applied.
The partial pack usually suffices to bring about the desired result, applying it to the lower extremities, or to the arms. In the whole pack a large
and heavy woollen blanket is spread upon the mattress, and over it is laid
a coarse linen sheet, well wrung out in water of a temperature from sixty
to seventy degrees, so placed that the patient can lie at the junction of
the middle, and right third of the sheet. When the patient is in position,
with the arms elevated, and provided with a wet turban, the right portion
of the sheet is drawn across the body and tucked.
The arms are lowered
tuted,
which
in the
DEMENTIA PARALYTICA
321
necessary to give preliminary doses of hyoscine. If the

excitement is extreme, forced feeding or hypodermoclysis
with normal saline solution (see p. 139) given twice daily
should be employed. The conditions of extreme anxious
restlessness
and agitation should
warm bath and
also be treated with the
necessary the use of the hypodermoclysis, but not infrequently these patients fail to yield
to any form of treatment, when all that remains to be done
prolonged
is
to
if
watch the patient carefully to prevent
injuries
and to
maintain nutrition.
In the
last stages of the disease,
extreme cleanliness
is
in order to prevent bedsores.

The bedmust
and
free from
be kept dry, clean, smooth,
clothing
crumbs, and the body frequently cleansed with cold water.
Alcohol or hardening applications are better withheld, and
instead the skin should be carefully rubbed with cocoa
most
essential
butter.
Frequent changes of the position of the body every
hour, day
of acute
and
night, aid greatly in preventing the occurrence
and hypostatic pneumonia. Acute

decubitus, once formed, is very obstinate and should be
treated surgically like an ulcer. Where there is a marked
tendency to the formation of acute decubitus and also where
it does not heal readily, the best method is to keep the
decubitus
and covered with the left portion of the sheet, which is drawn
body and securely tucked, especially about the neck and feet.
The patient is then covered with several woollen blankets. The duration
of the pack should be from one-half to one hour, and may be followed by
brisk rubbing with alcohol.
The duration of the partial pack may be
more extended than that of the whole pack. When the patient falls
asleep in it, it is not necessary that it be removed until he awakes.
There is no harm in an immediate renewal of the partial pack. It should
be remembered in the application of these partial packs, as well as in the
whole packs, that all air must be excluded from in under the cover of
to the side
across the
woollen blankets, for which purpose

cloth or oil silk.
many
use a final covering of rubber
322
the prolonged warm bath. The

nourishment during this stage must be liquid, in order to
prevent choking. Daily percussion of the lower abdomen
patient
continually
in
to detect distention of the bladder
and observation
condition of the bowels is also necessary.
of the
In case there
is
paralysis of the bladder, the patient should be regularly

catheterized, followed by a washing of the bladder with a
saturated solution of boracic acid.
Finally,
the
mouth
should be kept thoroughly clean. The paralytic attacks

may yield to ice packs on the head or to amylene hydrate
(thirty to sixty minims) or chloral hydrate, the former of
which may be given by subcutaneous injections in a five to

ten per cent, solution. If immediate action is demanded,
chloroform
may
be employed.
ORGANIC DEMENTIAS
VII.
THE term
here used in a limited sense, applying only

to those psychoses that are associated with organic disis
ease of the central nervous system,
and includes cerebral
Huntingdon's chorea, multiple
gliosis,
sclerosis,
cerebral
syphilis, tabetic psychoses, arteriosclerotic insanity, brain

tumor, cerebral trauma, and cerebral apoplexy.
This disease, described by Fuerstner,

presents numerous tumorlike accumulations of glia in the
superficial layers of the cortex with the formation of small
Gliosis of Cortex.
and atrophy
cavities
The
of the nervous tissue.
toms may be
tability,
of
chronic, the mental sympsudden onset with convulsions and irriis
but later there develops a progressive deterioration
with failing memory, accompanied by disorder of speech,

optic atrophy, and often tabetic symptoms.
Diffuse cerebral sclerosis,
the
in
supportive
dementia.
which there
tissue,
is
is
an extensive increase of
accompanied
by progressive
The mental symptons of HunHuntingdon's Chorea.

tingdon's chorea are distinctive, consisting usually of a progressive dementia with faulty
paralysis
1
of
memory, weak judgment,

Patients
thought, apathy, and irritabihty.
Facklam, Archiv f. Psy., XXX, S. 138.

Zinn, Archiv f. Psy., XXVIII, S. 411.
Diller, Am. Jour. Med. Sciences, Dec., 1889, April, 1890.
Hallock, Jour. Nerv. & Ment. Dis., 1898.
Sinkler,
Med. Rec., XLI,
p. 281.
324
are unstable in employment. Suicidal attempts are not

infrequent, and occasional homicidal tendencies are encountered.
if
Hallucinations
and delusions are infrequent, but

Anxious states,
present are unaccompanied by emotion.
outbreaks of anger, restlessness, sometimes develop. The

choreic movements are intensified by any mental excitement.
Physically
the
choreic
movements
of
Huntingdon's
chorea differ from those of acute chorea in that they are

less extensive and less frequent.
They involve the entire
trunk, limb, head and face, and are jerky, at times quick,
but often sluggish. The speech becomes hesitating, indistinct,
and
is rapid and hasty.

are rendered uncertain, yet it
indecisive, while the writing
The voluntary movements
is surprising to observe
how advanced cases maintain
their equilibrium in walking. The arms, head, and trunk
may be drawn into various awkward positions, the
patient
still
keeping
on
his
feet.
The
accompanying
photographic group (Plate 9), of three cases of Huntingdon's chorea, shows the rapidly changing attitudes of these
As
patients who were trying to look at the photographer.
muscular
the disease advances, general
strength wanes,
until in the end stages the patients become bedridden.
The deep tendon
muscle
reflexes are usually exaggerated,
irritability
increased.
and the
Sensation does not suffer.
Epileptiform and apoplectic attacks rarely occur.
The
course of Huntingdon's chorea is slowly progressive,

leading in the greater number of cases to considerable
dementia in the course of ten to thirty years. The mental

symptoms usually appear coincidently with the first of the
choreiform movements, but they may not appear for years ;
indeed, the writer knows of one case of Huntingdon's chorea
of fifteen years' standing in which the individual still conducts
While the
successfully a large and lucrative law practice.
ORGANIC DEMENTIAS
325
underlying mental process is one of progressive dementia,

as described above, the onset of the mental symptoms
may be sudden and of a manic character; occasionally
the
symptoms simulate the megalomanic phase
again the clinical picture
may
of paresis
be distinctly depressive in
accompanied by active hallucinosis and delusion

These various clinical states, however, are
formation.
character,
usually
only
while
episodic,
deterioration
progresses.
Marked dementia may have already become evident before

these various episodes appear.
Furthermore, there is no
relationship between the degree of choreic movements and
mental symptoms either group may be much more

Sometimes the
or much less advanced than the other.
the
choreic
movements improve considerably during the course
of the disease.
Where the mental symptoms antedate or

predominate in the clinical picture, there may be some
In such cases one must
difficulty in differentiating paresis.
Diagnosis.
of pupillary disturbances or musthe

cular paresis,
presence of only a hesitancy in speech
with hastiness and tremor in writing, without defect in the
depend upon the absence
content of speech and writing. In the mental field the

emotional irritability is more disturbed, and there is proportionately less defect of memory and orientation. The
history of Huntingdon's chorea in the antecedents should
leave
little
doubt as to the true character of the
disease.
The pathological anatomy of Huntingdon's chorea presents chronic leptomeningitis, with thickening of the pia
and small cell infiltration, general cerebral atrophy with
shrinking of the cortex, white matter, and basal ganglia.
The vessels exhibit extensive thickening of the adventitia
with increase in the perivascular spaces, and in places residIn four of the writer's cases, cell
uals of old hemorrhages.
326
shrinkage was observed, and in one case also grave alter-
Trabantan cells were present in most sections,

while glia nuclei were uniformly increased in the deeper
In all, vascular alteration was preslayers of the cortex.
ent, with round cell infiltration, as well as the presence
In one case there was
of free pigment about the vessels.
a slight degree of ependymitis, and in another, numerous
areas of thrombotic softening were found scattered over the
ation.
cortex.
Multiple Sclerosis.
ple sclerosis involves
When
the disease process in multithe brain, there develops more or
In 215 cases reported by Berger

in 1904, dementia occurred in only 24 cases (more than 10 per
The type of mental disturbance is usually that of
cent).
less
mental deterioration.
simple deterioration with failure of memory and judgment,

together with apathy, as seen in an unnatural complacency
and anergy. Besides the emotional apathy, there is some-
times present a tendency to uncontrollable laughter, and

other emotional outbursts of an episodic character. The
mental symptoms, however, are rarely of such pronounced

bring the patient to insane hospitals.
of multiple sclerosis may be confounded
case
atypical
character as to
An
with
dementia
paralytica,
particularly
if
nystagmus,
scanning speech, and intention tremor are tardy in appearance or absent. The burden of proof against dementia
paralytica then rests
upon the absence
of pupillary dis-
turbance, and of the characteristic paretic speech; while

in the mental field there is absence of faulty time orientation and prominent defect of memory.
Cerebral Syphilis.
In cerebral syphilis there are two
groups of cases: simple syphilitic dementia,
and
syphilitic
term are not included the

pseudoparesis.
mental disturbances occurring during the early mani-
Under
this
ORGANIC DEMENTIAS
327
such as the occasional deliria similar in nature
festations,
to infectious deliria, or the hysterical and neurasthenic

syndromes, in all of which syphilis seems to play the role
only of an exciting factor. The distinctively characteristic
only during the late period,

involvement of the cerebral vessels and the
syphilitic psychoses develop
when
there
is
development of gummata, vascular occlusion, and malacia.
The
vessel alteration is typically syphilitic and gives rise

to a profound nutritional disturbance in the cortex.
It is
from that occurring in paresis by the

is only very slight infiltration
into the adventitia of the vessels, and mast cells are rare
but there is a marked proliferation of the intimal cells,
to be differentiated
pathological fact that there
with a tendency to
vessel
typical.
The
form vascular foramina
The new
itself.
vessel formation
elastic fibres of
is
within the
extensive and
the vessels tend to split into
layers, while the vascular cells do not show pigmentation.

In simple syphilitic dementia there usually appears first,
defective memory and judgment, and some absent-minded-
ness, as well as lack of insight into these defects.
cident with the onset there usually occurs
apoplectiform seizure, which
may
some
Coin-
sort of
an
be either of a mild or
a severe grade.
The
tion.
Emotionally there is a slight degree of elapatients are fond of boasting of their strength
and plan extensively for the future. If there

to
be present some feeling of illness, they are
happens
confident of recovery. But more prominent still is the
and
ability,
greatly increased emotional irritability, which often leads

to strife and outbursts of passion.
Delusions of influence
and reference are sometimes present, also ideas of oppression and mistreatment, to which are ascribed sordid mobut such delusional ideas are transient and rarely
elaborated. Volitionally there is evident weakness of will,
tives;
328
shown
as
in their tractability
and
They tend
fickleness.
to
be thoughtless, disorderly in their work, neglect important

for unimportant matters, and do all sorts of extravagant
things.
Finally, there
is
a striking susceptibility to alcohol.
The course of the disease is usually slow, although it may

soon reach a stage of quiescence, with subsidence of the
prominent symptoms. Recovery is rare, in spite of antisyphilitic treatment, because the cortex has become extensively
involved.
There are occasional exacerbations.
Physically, the onset is usually with an apoplectiform attack J

and as the result of this there may be residual hemiplegia
or monoplegia, sometimes paresis of the eye muscles, some

slight fault of articulation, and also complete or reflex
iridoplegia.
This group of cases should also include that form of

progressive deterioration appearing in youth which arises
accompanied by forms
The pathological distinction between these
from congenital syphilis and

of paralysis.
cases
and juvenile
paresis
is
is
that in the former there exists
only the vascular lesions characteristic of syphilis. However, Meyer and Kaplan have described some cases in which
there was a mixture of paretic and syphilitic lesions.
To this group also should be added the cases described
2
Barrett, Bechterew, and Jurgens, in which the lesion

one of disseminated syphilitic encephalitis.
by
is
In Barrett's case the deterioration was very rapid, leading

to complete dementia and death within two months, while
in the case of Bechterew the course of the disease extended
through two years.

1
Amer. Jour, of Med.
Handbuch der
Sc., Vol. 129, p. 390.
path. Anat. des Nervensystems.
Flatan-Jacobsohn-
Minor.
*
Ref. Oppenheim, Syphilitische Erkrank des Gehirns.
ORGANIC DEMENTIAS
329
Syphilitic pseudoparesis includes those cases of cerebral
which present pronounced mental symptoms, in

addition to the evidences of focal brain lesions. The grada-
syphilis
tions
sis
between simple
syphilitic
are so imperceptible in
dementia and pseudopare-
many
cases that
some authors
do not attempt a differentiation, but describe both groups

under cerebral syphilis. The onset of pseudoparesis, as in
simple syphilitic dementia, may be with paralytic attacks.
attacks may be only syncopal, or aphasiform and of
short duration, or there may be loss of consciousness with
The
more or less severe paralysis. Such attacks may antedate

many months the mental symptoms, or they may be tardy
in appearing and sometimes they never develop.
Of the
mental symptoms, despondency is the first to appear, in
which either hypochondriasis or apprehensiveness predominate. The patients feel stupid, the food does not agree
with them,
they are self-accusatory, fearful, and speak

is a change of character, and they become
of infidelity. There
indifferent, forgetful, confused in
thought; at other times
they are irritable, excitable, and aggressive. Even delirious

Hallucinations are usually
excitement may develop.
and
often
present
very prominent, mostly of hearing,
though sometimes of sight and smell. The megalomanic

delusions so characteristic of paresis predominate and with
this there is emotional elation and a tendency to facetiousness, although
some patients are
and
and
patients are productive both in speech
hostile.
Many
irritable, suspicious,
and even neologisms ;

and reticent, and again others
writing, exhibiting incoherence
others are inactive, sleepy,

vary from one state to another.
Physically
besides the
and
form attacks, such as hemiparesis, hemianopsia, and paraphasia, etc., there may be present optic atrophy, an increase,
residuals of syphilitic infection,
of the earlier apoplecti-
330
absence or weakening, and particularly inequality of the

tendon reflexes, and complete or almost complete loss of
the light reaction of one or both pupils. Speech and writing,
however, show insignificant changes.

The course of the disease is slow, leading regularly to
a considerable degree of dementia. Some patients continue
orderly and are able to live at
ability to read
home; they possess the

and amuse themselves, and follow up a simple
daily routine, but are wholly incapable of profitable employment, lack insight into their condition, and are thoughtless
of the future. They continue oriented, but memory for
events of the psychosis and sometimes even for earlier life

is faulty.
The hallucinations and delusions tend to reap-
pear; these are never modified but only forgotten.

In the severer cases the dementia is more profound;
the patients are continuously confused, maintaining their

various expansive and persecutory delusions, exhibiting
and aggressiveness, or they may be

childishly good-natured and thoroughly tractable. Transitory conditions of profound stupidity and confusion arise.
restlessness, excitement,
Paralytic attacks, either epileptiform or syncopal, with or

without residuals, reappear with more or less regularity
throughout the course and
terminate the disease.
The
not be as progressive,
course of the
may
symptoms may
but after reaching a certain stage remain unchanged a

long time, until an exacerbation or some intercurrent disease causes death.
The
pathology of pseudoparesis exhibits the following

syphilitic lesions: meningitis, foci of malacia, gummata,
and particularly the
syphilitic vascular lesions.
out the entire cortex there
Through-
a hyperplasia of glia cells,

so much so that in places the "gliarasen" of Nissl is
found, indicating a profound degeneration of nerve cells.
is
ORGANIC DEMENTIAS
331
much involved, and there

of
development
glia fibres, and hence
very
Regressive changes
practically no reduction of the cortex.
The nerve
is
fibres,
also
however, are not
little
neuroglia cells. In the deeper layers

of the cortex there is a large increase of small round glia
may
be seen in
nuclei.
The
many
large vessels are deeply stained (Nissl's stain)
and the perivascular spaces are enlarged, although there is

no infiltration of the adventitia similar to what one finds
in dementia paralytica. The small vessels are greatly increased in number, dilated, and present many anastamoses,
appearing
everywhere
to
be
overlaid
with
glia
cells.
Nissl, this proliferation does not take place by

in
as
paresis, but by the formation of new vessel
budding
According to
openings through the thickened endothelium among the

numerous layers of the elastic coat. The muscular coat
Finally, rod cells are very rarely found. These
extend throughout the cortex, but to a varying degree, in places being almost imperceptible. They are always
more marked in the superficial layers of the cortex. Occa-
disappears.
lesions
sionally small old or fresh hemorrhagic foci are found.

The similarity of pseudoparesis to general paresis
striking that the differential diagnosis
is
very
difficult
is
so
and
depends mostly upon the presence and persistence of the

residuals of the paralytic attacks. These often exist from
the onset, which
is
not true in paresis. The characteristic

and writing, with the aphasia and
paretic faults of speech
stumbling over syllables, the transposition and the repetition

of syllables and letters, are absent, as well as the disturbances of the sensibility to pain. Memory is better than in
paresis, and except in the very bad cases, orientation is
preserved, i.e. names of persons are recalled and the pa-
remember striking
and also take some pride
tients
incidents in their environment,

in neatness
and
order.
At the
332
onset,
when
differentiation
is
most
difficult,
one observes
that in paresis the memory defect is out of proportion to the

disorder in the rest of the mental life, and hallucinations
are less prominent than in pseudoparesis.
The
treatment of
pseudoparesis presents but little hope, although the few

favorable cases following antisyphilitic treatment warrant a
trial in all (see p. 319).
In most cases where mental symptoms develop during the course of tabes, the disease terminates as paresis, but there are a few cases which never
Tabetic Psychoses.
become
paretic.
Very mild mental symptoms often appear
during the early stages of tabes, i.e. some fault of memory,

and an increased sense of fatigue, but more especially a
change in disposition.
hopeless,
cheerful,
Many
patients
become gloomy and
and have forebodings and fears, but others are

happy, and confident, sometimes reminding one
of the feeling of well-being of the paretic.
The
characteristic tabetic psychosis, however,
is
an acute
some excitement resembling the acute

The onset of the hallucinosis is sudden, with hallucinations of hearing, accompanied by some
anxiety and restlessness. Later hallucinations of the
other senses appear. The hallucinations are of a threaten-
hallucinosis with
alcoholic hallucinosis.
such as the voices of relatives calling

for help, threats against their lives, the odor of sulphur,
or the sensation of electricity, to all of which the patients
ing, disturbing
react.
attack
type
The duration of the

several months, when the
Orientation remains clear.
may be
symptoms
for a
few weeks or
often disappear suddenly.
There
may be
remis-
sions.
The
psychosis may resemble a short hallucinatory delirium, or it may simulate a chronic

psychosis with
hallucinations and paranoid delusions, both of persecution
ORGANIC DEMENTIAS
and grandeur.
Again
of these different
all
represent different clinical stages of

cess, similar to
one sees in
some
333
forms
may
the same disease pro-
the acute and chronic disease pictures which
and dementia
paresis, alcoholism,
of the chronic cases there
is
prsecox.
In
a similarity to syphilitic
pseudoparesis. Besides these forms of tabetic psychoses

there may develop in tabes the manic-depressive syndrome,
the catatonic orthe senile psychoses. The tabetic psychoses

are differentiated from the forms of paresis by the fact that
the disease process
is
not progressive.
The grade
of dete-
and furthermore, attention

not disturbed to the degree that it is in
rioration remains at a standstill,
and memory
is
paresis.
Arteriosclerotic
Arteriosclerotic
Insanity.
changes
in
the brain are very common

life, yet
it is doubtful if one is justified in considering them only as
evidence of early senility, particularly in view of the fact
in the senile period of
that extensive
arteriosclerosis
panying mental impairment.

that
the vascular
may
exist
without accom-
One must conclude
disease, in arteriosclerotic
either
insanity
is
not, in spite its great similarity, identical with that occurring in normal senility, or that in the former case the vas-
cular change is an accompaniment of only secondary importance in a disease process which is highly destructive of
nerve tissue.
especially
may
The varying extent
whether
it
of the vessel change,
involves the smaller or greater vessels,
account for the absence or presence of mental mani-
festations.
Alzheimer, Allgem. Zeitschr.

LIX, 695.
f.
Psy., LI, 809;
idem, LIII, 863; idem,
Binswanger, Berl. Klin. Wochenschr, 1894, 49.

Histologische und Histopathologische
Alzheimer,
Grosshirurinde-Nissl, Jena, 1904.
Arbeiten liber die
334
This psychosis appears about the sixtieth year; yet some

develop before fifty, but in the latter instance
cases
is usually present a strong hereditary tendency to

vascular disease. Alcoholism and syphilis may be regarded
there
When the disease occurs later in

may be associated with the charac-
as etiological factors.
life,
the arteriosclerosis
changes of the nervous tissue which are dependent upon the vascular changes. Alzheimer speaks
"
This form of disease
Senile Decay."
of these cases as
teristic senile
attacks especially the cortical vessels that pass in from

the pia, leading to the formation of deep wedge-shaped
foci with destruction of the nerve tissue and an increase
of glia.
There is regularly found, besides

the evidences of general arteriosclerosis, cardiac involvement, either cardiac hypertrophy or dilation, and interstitial nephritis.
rigid,
The
cerebral vessels are thickened
and
the dura and pia thickened, the latter being cloudy,

Several
entire brain is more or less atrophied.
and the
areas of hemorrhagic softening, either fresh or old, are usually

found in the cortex, and the ventricles are much dilated.
the numerous disease foci are found,

the
path of the altered vessels. In these
especially along
areas the nervous tissue has disappeared, being replaced by
a luxuriant growth of neuroglia, which shows little or no
Microscopically,
tendency to regressive changes.

addition to
the
usual
The blood
vessels,
in
arteriosclerotic changes,
namely,
a splitting and swelling of the elastica, thickening of the
walls, and regressive changes in the muscularis and adventitia, also
lymph
In the
to hyaline infiltration.
increase of connective tissue, pig-
show a tendency
spaces there
is
mentation, and granular cells. Comparing the normal with

the arteriosclerotic cortex, as seen inFigures 1 and 2, Plate 10
5
.X'.V^
*
*VV'*'
PLATE
Fig. 1
.''
v '.":"
*
V*r^W
10
Arteriosclerotic cortex.
Fig. 2
Normal
cortex.
..*'*"**
>:
^-
">
ORGANIC DEMENTIAS
335
apparent how extensive the degeneration of cells has

been. The few remaining nerve cells present a high-grade
it is
alteration in the intercellular tissue.
Deeply stained glia

nuclei are scattered everywhere, mostly surrounded by a
clear space, and gathered in groups, particularly about
The vessels themselves, both large and small,
vessels.
few
Some
nuclei, are hyaline and greatly thickened.
present
a
double lumen, which is very frevessels appear to have
quently found in the arteriosclerotic cortex. The disease
process is not evenly distributed throughout the entire
where only moderate changes are

one
cannot
Further,
judge of the extent of the
cortex, as there are foci
noted.
vascular change in the cortical vessels by the appearance

of the larger vessels in the pia, as the latter may be much
altered, while the
former show
little
change.
The nerve
fibres, both in the cortex and in the white matter, show

changes proportionate to the vascular disease. There
usually are numerous cavities in the white matter, particularly along the line of the vessels. This condition, called
crMe, presents a very characteristic picture. Where

this state is very pronounced and where the subcortical
region is more involved than the cortex, it has been called,
etat
by Binswanger, chronic
subcortical
encephalitis.
Clini-
cally these cases are characterized by very many limited

The
focal symptoms and a very pronounced dementia.
pyramidal tracts
may show atrophy in the pons and medulla.
Symptomatology.
The first symptoms
of arteriosclerotic
insanity consist of a diminution of energy, and forgetfulness.

The patients tire easily, lack the characteristic fresh-
and energy for work. They not only hesitate to

undertake anything new, but lack ability to do original
work. Emotionally, they are easily depressed, disheartened,
ness
at times whining
again, they
may be
irritable,
and sub-
FORMS OP MENTAL DISEASE
336
emotional outbursts. Emotional instability is apt

to be present, as seen in rapid changes from one emotional
state to another and in frequent weeping and laughing.
Patients are forgetful and flighty, and mix up their work.
ject to
always present a very definite feeling of illness

may even border on hypochondriasis. This may lead
There
that
is
Under the
to suicidal attempts.
some emotional
influence of alcohol or
a moderate degree of dazedness may

in
the course of the disease delusions of
Later
develop.
reference
stress
and particularly
of infidelity are prone to appear.
physical symptoms are more or less

pronounced attacks of dizziness, syncope, or even convulsive
attacks, which may be accompanied by paraphasic disturb-
The prominent
ances, disturbances of sensation, paresis,
attacks
Residuals
of
reaction
retained, or at
is
these
The usual vascular and

sclerosis are present,
These symptoms
particularly
if
is
paralysis.
persist.
Pupillary
only slightly sluggish.
symptoms of arterioalbumen in the urine.
cardiac
and there
may
usually
most
and even
is
remain at a
standstill for years,
the patient's method of living
is
carefully
regulated, but sooner or later apoplexy appears with its

With each recurring attack there is further deresiduals.
mentia, in which attention and memory suffer. Later

there develops complete disorientation, and indifference,
but at times there
is
childish irritability
and at others
happiness. Finally deterioration becomes so pronounced

that they have to be cared for and fed like little children.
Not
cases develop this degree of deterioration; indeed,

may be all grades of dementia. Aphasia, agraphia,
all
there
apraxia, and asymbolism, also word and mind blindness,

are frequent complications of these vascular lesions, which
tend to
than
it
make
the mental deterioration appear even greater

really is. There are old apoplectics of ten years'
ORGANIC DEMENTIAS
337
more duration who present only an increased sense of

mental fatigue, ill-humor, and some weakness of will,
or
rendering them particularly susceptible to outside influences.

In such cases the vascular lesions are supposed to be more
circumscribed or to have come to a standstill.
a group of cases of arteriosclerotic insanity that

deserve special attention; namely, those comprising the
There
severe
is
progressive
form.
These
cases
are
characterized
by a very rapid course leading to profound dementia and

death. The disease usually begins with an apoplectiform
attack, although there may have been prodromal headaches,
some
and lack
forgetfulness,
there develops a condition of

hensiveness,
of
energy.
Following this
marked anxiety and appre-
sometimes with pronounced delusions of a
persecutory nature, occasionally hallucinations and delusions

of self -accusation.
The patients are usually clouded and
much so
that they do not even understand what

goes on about them or what is said to them. They are
confused, so
irritable,
restless,
aggressive,
wandering about, attempt
escape, trying to jump from the window, or commit suicide.

Nocturnal restlessness is particularly marked. Nutrition
and
There regularly develop for

longer or shorter periods conditions of even greater bewilderment and more active restlessness. The patients
become even more clouded, so that they perceive practically
nothing and their attention cannot be fixed. Obstacles
placed before them are not perceived or are handled in a
sleep suffer profoundly.
wholly automatic manner. They will not avoid a test

needle, although they wince from pain.
Emotionally, they
manifest lack of feeling, although occasionally there may be
some anxiety or again some elation. Insight is absent.

The patients present an almost incessant, motiveless
The speech
activity, and they have no care of themselves.
338
is
usually wholly incoherent, sort of babbling,
and often
Such mental states usually end in death.

Yet the excitement may disappear, leaving the patient
in a condition of dementia which then becomes gradually
unintelligible.
progressive.
The
patients are wholly
listless,
disoriented,
and comprehend only the simplest questions. They have

neither the energy to busy themselves nor the interest to
mingle much in their environment. There is great emotional
weakness and the patients laugh and cry very easily; even
spasmodic laughing and crying may exist. In spite of
their great deterioration, they
may
be able to solve simple
mathematical problems, and not only recognize the members

of their family, but derive some enjoyment from their visits.
Physically, in addition to the residuals of the apoplectic
which paraphasic disturbances are apt to be

is also a peculiar impediment of speech
which may sometimes lead to genuine scanning. The
attacks, in
prominent, there
writing also presents marked changes. Individual letters

are barely legible, even though ataxia is not evident. The
patients lose their ability to write the single strokes into a
complete word. In the words that can be read omissions
These faults of writing are present from the

beginning and may be regarded as a sign of rapid fatigue.
The pupillary reaction is always maintained, although someare found.
times
it is
sluggish.
The
entire duration of the disease is
about four years, though there are cases of six to seven

years' duration ; and again, some cases run a course of only
The prognosis in any case is always inthe

general physical condition, especially the
by
condition of the heart, lungs, and kidneys, as well as the
a few months.
fluenced
age of the patient.
The
diagnosis of arteriosclerotic insanity may be difficult,

particularly the differentiation from paresis occurring in
ORGANIC DEMENTIAS
339
place, it must be remembered that

of the cortex, while in arteriolesion
paresis is a diffuse
late
life.
In the
first
sclerotic insanity there are
we
many
scattered foci.
Therefore,
find in paresis that the general psychic alteration is
more prominent than the physical signs. Paretics are

usually clouded and exhibit loss of judgment before the
in arteriosclerotic insanphysical symptoms appear, while
are
attacks
the
very often the startingapoplectiform
ity
the psychical disturbances. In arteriosclerotic

insanity disturbances of perception are more striking than
disturbances of memory, while in paresis both are equally
impaired. Emotionally, the paretic shows greater elation
point of
or depression ; while the arteriosclerotic patient is usually

indifferent and apathetic, or he presents either hypochon-
The
great elation
of some paretics and the profusion of delusions is wholly
lacking in the arteriosclerotic condition. Fabrication, aldriacal
despondency or indefinite
fear.
though a prominent symptom in paresis,

in
is
seldom indulged
by the arteriosclerotic patient, and then
it
is
of
an
altogether different character, being meagre and without

the florid embellishments of the paretic fabrication. These
patients also present in a marked degree lack of mental
power ; yet at times they suddenly surprise one with their
knowledge, although at other times they appear much de-
There does not appear to be such a complete loss

of mental power as in paresis, but an inability to control it,
and corresponding to this there is a greatly increased sense
mented.
which
not present in paresis. Finally, in spite

of the apparent great dementia, many of the arteriosclerotic
patients remain oriented to the end, recognize their relatives
of fatigue
is
and enjoy their visits, having good insight into their physical
and mental helplessness.
Further, physically there is a marked contrast between
340
the paretic and arteriosclerotic symptoms.

In the arteriosclerotic state the physical symptoms are prominent ;
such as persistent, well-defined paralyses
with spasms,
word blindness, mind

and
blindness, hemianopsia,
astereognosis. The speech
disturbance is more of the type that arises from paralysis,
while in writing, simple omissions are more prominent than
the ataxia and the transposition of syllables seen in paresis.
The pupils remain
Very often perseveration is present.
contractures, aphasia, asymbolism,
normal.
The presence
of arteriosclerotic changes elsewhere
body point to a similar condition in the brain, but

the former is no sure criterion of the extent of the brain
in the
involvement.
In the
earliest stages of the disease,
when the
be most
diagnosis may
difficult, the predominance of the
general physical symptoms over the mental symptoms,
the latter of which are more apparent to the patient himself
than to the
friends,
always favors a diagnosis of arterio-
sclerotic insanity.
dementia
may
arteriosclerotic insanity only
with
Simple
syphilitic
be differentiated from
difficulty, particularly
in the early stages.
In the syphilitic psychosis, we perceive a slower development of the 'symptoms, and the dis-
turbances of
memory and
while the focal
perception are less pronounced,

are more uniform, less manifold
symptoms
and variable than in the arteriosclerotic condition; again,
the tendency to oculomotor disturbance, of optic disorder,

and paralysis of the pupils is of importance as well as the
knowledge of syphilitic disease elsewhere in the body.

In differentiating pseudoparesis we find that the course is
not as progressive as in arteriosclerotic insanity, while
the hallucinations and delusions are not nearly as promi-
nent
and are often absent
The degree
in
arteriosclerotic
of deterioration does not
insanity.
become as great;
ORGANIC DEMENTIAS
memory
is
better, orientation is retained,
341
and the patients
continue conscious.
The
of
all,
treatment of arteriosclerotic insanity demands, first

rest, freedom from occupation, avoidance of excite-
ment and
all articles of diet
system; namely, alcohol,
Forms
that interfere with the vascular

coffee, tea,
and much tobacco.
of excessive exercise should also
be avoided, as
It is doubtful if
swimming, rowing, bicycle riding, etc.
the administration of potassium iodide or the employment
of foods containing calcium have any beneficial effect.
In the later stages of the disease the patients are apt to
become bedridden, and require very careful nursing.

Cerebral Tumor.
In cerebral tumor all cases do not
develop mental symptoms. Of 318 cases Gianelli discovered
but 299 that developed a psychosis.
much
involved or
if
the tumor
is
If
the cortex
is
not
of slow growth, mental
On the other hand, they may

a small circumscribed growth, but
always the possibility of chemical
symptoms may not appear.

develop where there
in such cases there
is
is
or other destructive agencies extending over a broader

If the growth is of considerable size, mental symparea.
toms are sure to appear.
According to Schusters, tumors

of the hypophysis in about two-thirds of the cases develop
a psychosis, of the cerebellum in one-third of the cases, and
stem in one-fourth of the cases.

In these cases the influence upon the cortex may arise
from increase of the general pressure and interference
with the blood supply, both venous and arterial. In tumors
of the
of the corpus callosum the destruction of the association
beween the two hemispheres has some effect upon the

mentality. In general, then, the effect of tumors outside the
cortex upon the mental processes depends upon their size.
This theory receives some support from the fact that extenfibres
342
sive tumors, involving even the cortex,
may run their
course
without mental symptoms, if the tissue is gradually destroyed,
and not put under pressure ; while, on the other hand, even
small tumors of the brain are often observed to produce
pronounced mental symptoms because they exert either
local or general pressure.
Schuster observes in his ex-
perience that those tumors lying nearest the cortex produce

far more mental symptoms than those lying at a distance.
The
latter cause only a simple progressive disappearance

the mental activity, indicating a cortical paralysis,
while the former indicate signs of irritation.
of
The mental symptoms
of brain
tumor are naturally quite
Schuster in about fifty-six per cent of 775 cases of

brain tumor accompanied by mental symptoms finds that
these symptoms consist of a gradually progressive mental weakness.
The patients become sleepy, inattentive,
varied.
forgetful,
easily,
unproductive
and are without
in thought, indifferent, fatigue

either their characteristic energy or
prolonged work. Mental application calls for

an unusual effort. They exhibit a degree of drowsiness and
stupidity which may even extend to coma. In addition
facility for
to this, there develop the various symptoms indicative

of tissue irritation and destruction, the character of which
depends somewhat upon the situation and growth of the
tumor, such as apoplectiform attacks, convulsions, aphasia,

hemianopsia, etc.
Where
these
symptoms
are slight or
altogether absent, the picture may appear very much like

a case of paresis of the demented form. In such cases the
depends upon the absence of reflex pupillary

disturbance and the absence of speech disorder.
Other symptoms emphasized by Schuster are greatly
differentiation
increased irritability with transitory periods of excitement,

less often periods of despondency with delusions of per-
ORGANIC DEMENTIAS
and
343
Tumors
of the dorsal regions

of the brain are apt to be accompanied by delirious states
secution
self-accusation.
with pronounced hallucinosis, although mental symptoms

accompanying tumors of this region are less frequent than
in
tumors of the frontal
lobes.
Occasionally in brain tumors there exists a condition

of elation, even with distractibility of attention, productiveness, flight of ideas, and some increased activity; but more
frequently there exists a condition of childish happiness,
with a tendency to joking and punning. This mental

state Schuster finds more characteristic of tumors of the
frontal lobes.
Finally the hysterical syndrome
may
exist
in brain tumor.
The
differential diagnosis in this state as well as in all of
those already mentioned depends almost wholly upon

the presence and character of the physical symptoms,
indicative of focal lesions.
As regards
treatment,
one should
resort to anti-syphilitic treatment in cases of suspected

syphilitic
gumma, and
location of the
tumor
to surgical interference where the

In
suitable for such procedure.
is
recent years there is a gowing tendency to operate in all

cases of cerebral tumor, if only for the temporary relief
of distressing symptoms.
Brain Abscess.
Brain abscess
be unaccompanied
be of slow developby mental symptoms, particularly
ment. In recent traumatic abscesses stupor is a prominent
may
if it
symptom. The patients are completely disoriented, and

do not comprehend what is said to them. They are restless,
Beresistive, and sometimes in a dreamy, delirious state.
sides this, there may develop catalepsy, aphasia, epilepsy,
slow pulse, Cheyne-Stokes breathing, and other signs of
irritation.
Cerebral Apoplexy.
The mental symptoms
of cerebral
344
hemorrhage, embolism, and thrombosis usually depend in

small measure only upon the focal disorder. Immediately
following the apoplexy the patients are usually unconscious,
completely disoriented, and perform all sorts of strange
Sometimes there develop transitory states of active

excitement, with noisiness and display of resistance. These
acute disturbances usually disappear in the course of a few
acts.
days or weeks, leaving as residuals the symptoms of the

original disease process, which almost always is an arteriosclerosis
or
endarteritis.
syphilitic
The
patients
may
become wholly clear mentally, or may exhibit the various

symptoms of arteriosclerotic or syphilitic insanity, already
In embolism, the mental symptoms
sufficiently described.
and
However, the perentirely disappear.
may suddenly
sistence of aphasic or paraphasic disturbances
it
appear that the patient exhibits
weakness than really

1
Cerebral Trauma.
head
may make
more marked mental
exists.
Mental disturbances accompanying

designated as traumatic insanity,
widely
a
considerable
comprise
group of cases. It has been demonstrated that in cases of severe trauma there exist
injury,
profound cellular changes in the cortex, and besides this,

areas of contusion and punctate hemorrhages at a distance
from the point of injury, particularly on the

of the brain,
and
temporal and
occipital lobes.
inferior surface
at the tips of the frontal lobes, in the
insanity in the narrow sense comprises

traumatic delirium and traumatic dementia (post traumatic
Traumatic
constitution,
Meyer).
Cerebral
trauma should
also
be
regarded as a prominent etiological factor in epilepsy and

in the traumatic neuroses.
Insolation is regarded as a
form of cerebral trauma.

Meyer, Am. Jour, of Ins., LX, 373 Guder, Die Geistesstorungen nach
Kopfverletzungen, 1886; Koppen, Archiv f. Psy., XXXIII, 568.
1
ORGANIC DEMENTIAS
Traumatic
345
delirium
(primary traumatic insanity) dethe

loss
of consciousness incident to the
velops following
head injury. The patients, instead of becoming clear,
present befogged states with complete disorientation, difficulty of thought, and very little or no memory of the accident.
Sometimes the amnesia includes a period just preceding

the accident, and not infrequently there is amnesia for other
isolated periods of the
poorly,
There
ally,
of the patients. They perceive

difficulty in seeing the connection of things.
life
and have
often a marked tendency
is
they are
to fabrication.
irritable or indifferent.
They
Emotion-
are apt to be
restless, at times aggressive, often whining and talking

considerably, the content of the speech being rambling and
incoherent.
ent.
There
Delusions and hallucinations are rarely presno_jJej|r_infught Jnto^jthe.- disease, and the
is
patients speak of themselves as being perfectly well. This

state is sometimes accompanied by transitory aphasic
The symptoms of traumatic delirium may last for

many weeks, some cases persisting for several months,
states.
after which the patients usually recover, although sometimes

the condition of traumatic dementia supervenes.
In traumatic dementia there develops sooner or later after
the immediate effects of the injury, and in some cases

even where there never has been a loss of consciousness,
a change of disposition.
This alteration
indefinite that all the friends can say
is
even be so
that he is a changed
may
man.
This change usually consists of an increased susceptito

bility
fatigue; i.e. unusual fatigue upon slight exertion;
some forgetfulness, confusion of thought, inattention, un-
wonted
dency
timidity, occasional slight despondency, with a tento complain of many disagreeable sensations, as dizzi-
head pressure, and a certain sense

of heaviness and stupidity. Accompanying these complaints
ness, ringing in the ears,
346
usually a keen sense of illness. The patient is

irritable, irascible, and at times even exhibits some passion.
Isolated convulsions sometimes develop, or even attacks
there
is
Not only a tentemporary dazed spells.

dency to alcoholism, but also a striking intolerance to
of petite mal, or
the influence of alcohol and other drugs, often appears,

as well as great intolerance to the sun's rays. The capacity for employment is impaired, in explanation of
which the patient refers to various subjective sensations.
Even games and conversations are avoided for the same
reason.
The
but
is
Many
is
not distinctly progressive,
sometimes characterized by distinct exacerbations.

of these exacerbations can be traced to alcoholic
indulgence or trivial emotional causes. Deterioration is

most pronounced where the trauma is associated with
alcoholism
or
arteriosclerosis, or
where
the
injury has
occurred during youth. Usually there are some nervous

manifestations indicative of focal lesions of the brain, such
as changing pupillary disorders, tremors, paresis of facial
muscles, and exaggeration of the tendon reflexes. There
are a few cases of traumatic dementia which for a time

like paresis,
may
but are differentiated from this disease
appear
by the changing character of the pupillary disturbance
and the
and the relatively

slow progress of the disease. Undoubtedly some cases of
paresis do develop from brain trauma as a starting-point.
This, however, is a mooted point, yet there are many
observations, including those of Meyer and Koppen,
which indicate its validity. Some of the doubtful cases
of traumatic dementia, simulating paresis, have presented
on post-mortem examination an extensive arteriosclerosis
characteristic speech disorder,
of the brain.
ORGANIC DEMENTIAS
347
The
treatment of traumatic insanity rests in early cases

with operative procedure, particularly where there is an
indication
of
focal
surgical interference,
of focal irritation,
is
disorder.
In
traumatic
even though there

far less successful.
may be
dementia,
indications
INVOLUTION PSYCHOSES
VIII.
THE
forms of mental disease, described as involution

psychoses seem to bear some relationship to the general
physical changes accompanying involution. Undoubtedly,
the forms of mental disease included here can occur in other
periods of life, also there are many other psychoses unrelated

to involution that may occur during the involution period;
as for instance, the alcoholic and infection psychoses, manicdepressive insanity, etc. The mental disturbances of the
early involutional period are of a somewhat different stamp
than those characteristic of
symptoms common
to both.
though there are many

Those occurring in the former
senility,
period are called melancholia and presenile delusional insanity, and in the latter, senile dementia.
A.
Melancholia
MELANCHOLIA
restricted to certain conditions of mental
is
depression occurring during the period of involution. It

includes all of the morbidly anxious states not represented in
other forms of insanity, and is characterized by uniform
despondency with fear, various delusions of self-accusation, of
persecution,
1
and
of
v. Krafft-Ebing,
De
a hypochondriacal nature, with moderate
Die Melancholic
Christian,
6tude sur
la Me*lancolie,
1876; Voisin,
M&ancolie, 1881; Dumas, Les Etats Intellectuels
dans la Melancolie, 1895; Roubinowitsch et Toulouse, La Melancolie,
1897. Hoch, Rev. Ed. of Reference Handbook of Medicine, p. 117.
la
348
MELANCHOLIA
349
clouding of consciousness, leading in the greater number of

cases, after
a prolonged course,
to
moderate mental deteriora-
tion.
The
Etiology.
disease
is
essentially
one of the early

between the ages
senile period, as the majority of cases occur
of fifty
and
sixty.
Sixty per cent, of the cases are
sixty.
disease tends to occur
some
relation
to
seldom develops under forty or over
It
somewhat
the
women,
earlier,
climacterium.
in
whom the
apparently bearing
Defective heredity
occurs in only a little over one-half of the cases, but it is a

striking fact that the parents and brothers and sisters of
melancholiacs frequently suffer from apoplexy, senile de-
External influences, such as mental

shock, especially illness and loss of friends, acute and
chronic diseases, and surgical operations, seem to play a
mentia, or alcoholism.
rather important role as exciting causes of the disease.

In many cases there is found
and its attendant results in the heart

Sometimes there is evidence of beginning brain
Alzheimer found, in the deeper layers of the
addition to the changes in the nerve cells, an ex-
extensive arteriosclerosis
and kidneys.
atrophy.
cortex, in
production of the neuroglia.

The onset of the disease
Symptomatology.
tensive
and
fibril
is
gradual,
months and even years by many

indefinite prodromal symptoms; such as, persistent headache,
is
often preceded for
vertigo, indefinite pains, general debility, insomnia, loss of
appetite, constipation, palpitation of the heart, ringing in the
and increasing difficulty with work. The patients at

first become sad, dejected, and apprehensive, and find no
enjoyment in their work or home environment. They are
overshadowed by doubts, fears, and self-accusations, and can-
ears,
not be consoled.
confused,
They feel ill, complain of being dull,

and forgetful, and find it difficult to do anything.
350
During this period there are occasional days when they are
free from fear and sorrow.
Delusions of self-accusation become prominent. Sometimes the patients accuse themselves only in a general way:
they are wicked, are not worth anything, have made fools of
themselves, have been impure, and are not worthy to live.
But usually the self-accusations refer to definite experiences.

Patients become retrospective, and refer to many misdeeds
in going over the past life which are held as an adequate
Remote and often insignificant facts
basis for their sorrow.
are recalled, such as the stealing of fruit in childhood, disobedience to parents and neglect of friends, which now cause
them the greatest sorrow and anxiety. Their whole life has
been made up of similar misdeeds.
patient was miserable
because she had requested her sick sister to remain out of the
kitchen another, because at the death of her mother she had
;
allowed
property.
herself
Many
to think of
and mention the
division of
refer to former sexual indiscretions.
Some
patients reproach themselves for everything; they cannot

do anything right. Everything in the environment is a
source of special anxiety to themselves; the lamentations of

a fellow-patient are directly the result of their own misdeeds.
Others want for food
if
they
eat.
These references vary from
day to day, or may be maintained with great firmness for a

long time. Quite often the self-accusations refer to religious
The
patients are not as fervent in prayer as

formerly; they no longer possess real religious feeling, or
have sinned against the Holy Ghost, are possessed by the
experiences.
devil, etc.
Occasionally their self-accusations center about
actual misdeeds, which during health long since ceased to
cause anxiety.
In addition to these self-accusations the patients sometimes harbor the conviction that they themselves must be
MELANCHOLIA
one of their children
killed or that
is
351
to be sacrificed.
They,
"
furthermore, are constantly rinding "signs" and
meanings"
which God has intended for them. There are often associated with these delusions of self -accusations
many
other
depressive delusional ideas, chief among which are the fears

The patients believe themselves so wicked
of punishment.
that
God has
forsaken
them and they
are
doomed
to hell,
they will be turned out of their home, brought to court,

thrown into prison, or killed outright. People are waiting
outside to carry
them
off,
a death warrant
is
already signed.
no need of taking food; they would rather starve

and suffer for their misconduct, and even ask to be executed.
Not infrequently they exaggerate their misdeeds and confess crimes which they have never committed, in order to
There
is
secure severer punishment
and
to relieve their guilty con-
sciences.
In other cases the delusions are of
a more hypochon-
Patients insist that they are the most unfortunate individuals in the world; the stomach is gone, the
lungs are filled up, the limbs shrunken, and all sensation
driacal nature.
lost.
The brain and nerves
former sexual abuse.
They
are rotting away as the result of

fear that they are dying of con-
sumption or cancer, and that they are going out of their minds
and must end their days in an asylum. They maintain that
the body has been poisoned, destroying all appetite, and now
they must starve.
They also express considerable fear
for themselves and families; they will be deprived of their
home, some great calamity will visit them, the children will
they themselves will be robbed and

driven from the church and damned by God.
die, or
killed, will
be
These depres-
sive delusions so thoroughly influence their actions that they
become
seclusive, eat sparingly or not at
money, and
clothe themselves
and
all,
refuse to spend
their children scantily.
352
They
to
give
up everything because they have only a
short time
live.
Hallucinations of hearing and sight often accompany this

condition, but they are usually indefinite and of short dura-
The patients also refer to an inner voice which commands them to commit suicide, or constantly repeats to them
that they are wicked and guilty. The consciousness is
usually clear. The patients are well oriented, with the
tion.
possible exception of
some delusional
ideas, in accordance
with which they may claim that they are in a prison, or they
may mistake strangers for acquaintances and insist that the
ideas,
which they receive are not real; but in spite of these

it may be readily seen that apprehension itself is not
much
disordered.
letters
is coherent and relevant, but the content is usumonotonous

and centered about the depressive ideas, to
ally
which they constantly recur, recounting their various misdeeds and fears. Very often they show a tendency to repeat
Thought
certain phrases, as
"
want to
see
"
my
Let
me
go home,"
"
children,"
"
Let
want to
me
see
go home;
my
"
children."
usually some insight into the change which they have

undergone and they will complain that their head is not right,
There
is
but they
fail
to recognize
many symptoms
of the disease as
such.
There
a smaller group of cases of melancholia of involution occurring somewhat later in life, in which the various
is
delusions of self-accusation, of fear, misfortune, and persecuIn these cases

tion are much more fantastic and senseless.
the entire environment appears to the patients to be changed.

Their home is transformed into a dungeon, into a house of ill
from which there are no means of

Things about them seem unnatural and have a
repute, or a deserted prison
escape.
gloomy aspect; passing carriages are regarded as a funeral
MELANCHOLIA
353
procession; the tolling of the church bell indicates that some

one has died. A spoon lying on the table means that medicine has been taken
death.
by some one who
Hammer and
nails
is
now
found on the
at the point of
floor signify that
scaffold is being secretly built for their execution.

Chance
remarks have a hidden meaning. Their food is the flesh and
blood of their relatives. Everything is awfully changed for
them; friends and
relatives are not real;
the sun and the
moon look different; the end of the world has come; and they
now to be passed into a lion's den. The patients accuse
are
themselves of horrible crimes, for which they are exiled or

must die on the gallows; have murdered their husbands,
devoured their children, or have brought sin upon the whole

world. All wickedness is due to them ; they have desecrated
the communion bread, or have spat upon the image of Christ.
are totally unworthy, should be buried alive, no one
should speak to them, hanging is too good, and they should
They
be thrown into molten metal.

In some cases the so-called "
nihilistic delusions" (delire
de negation) predominate, when the patients claim that

nothing exists, there is no more food, no more houses, no
more trees, no cities, no day or night, no sun or moon, no
living being.
They
are alone in the universe, as there
is
no
They themselves have no name, no wife, no children.

cannot
Their body is all
They
eat, cannot speak, cannot die.
shrunken up, their bowels never move, and food has been
world.
accumulating in them for months. They no longer possess

a heart or lungs; they cannot breathe or even walk.
Extremely absurd hypochondriacal ideas are apt to be

expressed. The patients claim that they have no breath, the
blood has stopped circulating, the veins have dried up, the
eyes are rotting away, maggots are crawling under the skin,
their brain
2A
is
solid rock, their limbs are
transformed to hoofs
354
and the
face to that of a wild animal.
Occasionally sexual
delusions of a silly character are present, the patients
main-
taining that they have been outraged at night, are now in a

house of ill repute, or surrounded by men disguised as
women. These depressive delusions are definite, coherent,
and usually
well-retained.
There are a few
cases, especially
those with progressive mental deterioration, in which a few

expansive delusions appear.
Hallucinations, especially of hearing, and also of sight are
prominent. Voices and bells are heard, the devil commands
them, strangers insult them, and they hear the evil thoughts
of others.
They see strange forms beside them at night,
moving bodies and spirits. Occasionally they detect strange

odors and tastes in food, and smell vapors at night.
Consciousness in these cases is usually clouded and there
is some disorientation for time, place, and persons.
The
train of thought is somewhat confused and monotonous, with a
I
it
"What
do?"
is
did I
do?"
"My God
sometimes surprising to find
how
"
What did
my God !" Yet
tendency to repeat compulsively such phrases
as,
well patients answer
questions and describe their symptoms. Sometimes the

patients are partially conscious of the nature of their illness
and complain that they have been made
foolish
and crazy by
poison placed in their food or hypnotic influence.
In other
cases the patients are wholly unable to recognize the contradictions in their absurd statements: at one minute they will
claim that they have been destroyed by poison, and at the

next that they cannot die.
The emotional attitude is uniformly one of depression. The
basis for this emotional depression seems to be fear, a feeling
of oppression,
an inner
anxiety.
Some
patients claim that
a heavy weight were upon the chest. They are

timid, uneasy, and feel as though homesick. The fear is
it is
as
if
MELANCHOLIA
increased
by
to arouse in
association with those
them the deepest
new environment
create
355
who
are accustomed
feelings, while strangers
little
emotional reaction.
and
Emo-
may be present at times, when the patients

are greatly agitated, and may even present a dreamy disturbance of consciousness. These frequently follow visits of
tional outbreaks
relatives or
some unusual occurrence.
In conduct, the patients no longer feel the impulse to work;

work is hard to finish. Yet they cannot remain quiet, they
cannot remain in bed, and wander about the house in an
They complain, lament, and pray; visit

and
the
clergy in order to receive sympathy,
physicians
although they know that no one can help them. Many
aimless manner.
patients develop a feverish activity, they beg piteously for

work, they work at night and struggle along until
completely exhausted
their sorrow and fear.
The countenances
their anxiety.
in
order to take their minds off
of the patients give clear evidence of
Occasionally in very severe cases there
appear transiently
no means represents an elated emotional
an expression
may
state,
which by
but is rather
feel
compelled to
peculiar indefinite laughter,
of desperate irony.
They
They always have something to

communicate to the doctor, but one finds that it is always the
same old story. It is a striking peculiarity that these patients
become quiet when transferred to a new environment.
They become natural in their manner, are approachable, and
talk about their condition.
are able to conceal their anxiety. They claim that everything

will be all right again if they could only return home and to
work, but careful observation shows the real depth of their

emotional excitement. After the disease has been in existence some time, the patients may be able to remain quiet and
more or less indifferent for a much longer time. But as soon
356
as one comes into close companionship with them, he will

observe occasional evidences of emotional outbursts.
Commands
are carried out without delay, unless they
some anxiety. The individual movements are usually

and unrestrained, although they are usually performed
create
free
without any special strength or rapidity, especially in patients

much reduced physically. There is no striking disorder in
writing.
The
and many even refuse food

sometimes
because
altogether,
they wish to die, at others
because they are not worthy of food. Others suspect poison
or excrement in their food. Similarly, patients refuse to
patients eat irregularly
take medicines and to bathe themselves.
Some
patients are
untidy and even soil themselves.

The tendency to commit suicide is more pronounced and
more to be guarded against in melancholia than in any other
form of mental disease. The desire to end life may be the
outcome of deliberation, or because they are repudiated by

God. But usually the thoughts of death arise suddenly and
impulsive. Not infrequently they suddenly develop
during convalescence. Often their attempts at suicide are
are
not remembered. Sometimes the suicidal attempts are among

the first symptoms of the disease. Every melancholiac should,
therefore, be regarded as a dangerous patient,
so,
ing
the more conscious he
is
and the more
and the more capable of concealcommit suicide, these
Determined to
his
anxiety.
patients resort to all sorts of devices to accomplish their
purpose. Some attempt to drown themselves in the bathtub, others
ram
their heads against the wall;
many hang
or
attempt to strangle themselves by tying something about

In their agitation they seem to be quite insensible to pain.
One of my patients reduced her scalp to
their necks.
pulp with a hammer, fracturing her skull in several places.
MELANCHOLIA
Other patients swallow
that they can secure.
357
glass, nails, ink, or in fact
anything
In case the anxiety is accompanied by greater excitement,

the patients cannot remain quiet, but pace back and forth,
wringing their hands, pulling at their hair, moaning and
lamenting until so hoarse that they can barely speak aloud.
In their great anguish they persistently pick at their nose,
face, or fingers until
smeared with blood, pull out their
and pound themselves. Kraepelin

extreme picture really belongs to
this
whether
questions
melancholia or should be classified in a group as yet unThese cases, anatomically, usually present
differentiated.
severe and extensive lesions in the cortex in which there
hair, tear their clothing,
is
destruction of very
many
The
cells.
an early and promiscanty, much disturbed by
Insomnia
Physical Symptoms.
nent symptom.
nerve
sleep
is
is
dreams, and unrefreshing. Occasionally there are observed

the early signs of the senile changes; such as attacks of
dizziness, sluggish pupillary reaction, paresis of the facial
muscles, and tremor of the tongue
and hands.
The
patients
also complain of uncomfortable sensations about the heart;
"
a sort of tension, a pressure, or an anxious feeling," which
The muscular power is diminis regularly worse at night.
ished and there

nutrition suffers
The
is some general physical weakness.
and the weight falls. Appetite is poor or
completely lacking, the bowels are very sluggish, the tongue

The mucous surfaces are
coated, and the breath foul.
anaemic.
The temperature frequently remains below normal.
Circulatory disturbances are often present; as, cyanosis,

The pulse may be
coldness and edema of the limbs.
small and irregular or slow, and the arteries may give
evidence of
beginning
sclerosis.
Other changes, indica-
tive of senility, are sluggish reaction of pupils, grayness of
358
the hair, cessation of the menses, dryness and harshness

of the skin.
There
Course.
duration, and a
of recovery the
is
still
a gradual development, a prolonged

In cases
more gradual convalescence.
whole course
lasts at least
twelve months to
Short remissions, during which there is only a

years.
partial disappearance of the symptoms, are characteristic of
two
the entire course.
There
often present a daily improvean exacerbation of the symptoms
is
ment toward evening, and

during the morning.
Exacerbations often arise as the result
of annoyance, fatigue,
and
excitation, such as that
visits.
of the sleep
induced by
and
nutrition,
gradual improvement
an increase in weight, may be regarded as a favorable sign. The remissions become longer and more marked,
and the anxiety gives way to irritability and fretfulness; the
patients then begin to display interest in work and reading.
especially
Even when convalescence is well established, it is not unthem to have " bad days," during which they are
troubled and fearful.
The distinguishing characteristics of melanDiagnosis.
usual for
slow development, uniform

course, long duration, gradual improvement, and doubtful
of
cholia
involution
are
These characteristics only partially suffice for

of melancholia from the depressive
of
phase
manic-depressive insanity. In addition, the disprognosis.
the
differentiation
quietude of the melancholiac

dejected and hopeless
is
contrasted with the
more
is
the manic-depressive
especially well marked in the
early stages of the disease,
when the melancholiac shows
patient.
more
This difference
and restlessness and the manic-depresa dismal despondency and sadness. In melanemotional attitude is much more uniform.
clearly anxiety
sive patient
cholia
attitude of
the
Although the melancholiac
may show some
variation in the
MELANCHOLIA
always present, and it

in manic-depressive in-
intensity of his feelings, the anxiety

is
not possible, as
sometimes
it
359
is
is
by consoling or joking with them, to make them cheerful and smiling. Furthermore, in the psychomotor field we do
sanity,
not observe the retardation, which

in manic-depressive insanity.
is
The
usually so pronounced
patients have no
culty in expressing themselves orally or
unhampered
in their
movements and
by writing
If
actions.
diffi-
they are
they hap-
pen to be silent and refuse to speak, it is evident that this

arises from their desperation or their delusions.
They are
usually communicative
can secure consolation.
The
and
talkative
enough whenever they
by no means as easy
some of the
mixed phrases of manic-depressive insanity, in which the despondency is associated with some excitement and not with
differentiation is
retardation.
in
In such cases the distinction depends upon the
mixed phases is usually

accompanied by grumbling and
fact that the emotional state in the

less
anxious than
irritable, is
at times
faint-heartedness, that restless patients can be

influenced
easily
by conversation to become quiet and even
and
cheerful,
finally, that the excitement is not an expression
of the feelings, but
in
no
an independent disturbance which stands
relation to the intensity of the feelings.

depression of catatonia developing during involution
The
distinguished from melancholy by the presence and persistence of hallucinations and the inaccessibility of the patients.
The melancholiac is resistive and inaccessible only in conis
nection with his anxiety or his delusions. He is usually

influenced by conversation, and participates in the conversation
when
visited
by
friends,
while the catatonic shows
emotional indifference, negativism, and constrained and

manneristic conduct. The uniform lamentation and wringing of the hands in melancholia contrasts with the senseless
stereotypy of the catatonic.
360
characteristic
Symptoms
of
senile
dementia sometimes
develop in melancholia, rendering the prognosis less favorable.

Such symptoms are, chiefly, the interference with the
impressibility of
memory, the tendency
to fabrications, loss
of orientation, emotional indifference, silly obstinacy,
nocturnal restlessness.
The
fantastic
and
nihilistic
and
character
not an unfavorable sign, but senile physical

changes are; namely, decrepitude, atrophic changes in the
skin, bones, and muscles, and the evidences of arteriosclerosis
of delusions
is
in the heart
and
vessels.
Melancholia has no connection with the arteriosclerotic

brain lesions.
The depressed
states occurring in arteriosck-
hypochondriacal and accompanied

by evidences of dementia and of severe brain lesions.
Considerable trouble may be experienced in differentiating
rotic insanity are distinctly
the depressed form of dementia paralytica. In melancholia

one finds a subacute onset following definite prodromal
less clouding of consciousness, a more
consistent emotional attitude, and absence of evidences of
mental deterioration early in the disease, while in dementia
symptoms, greater or
a gradual onset with early evidence of

mental deterioration, defective time orientation, poor judg-
paralytica there
ment
is
and contradictory delusions.

silly
the
emotional
attitude does not always corFurthermore,
respond with the ideas expressed, and consciousness is more
and
memory,
deeply clouded.
The prognosis is not favorable, considering

Prognosis.
that only one-third of the cases fully recover. Twentythree per cent, of the cases improve so as to be able to return
home and
live comfortably,
sometimes aiding in the main-
the family, twenty-six per cent, become deand

nineteen per cent, die within two or three years.
mented,
The patients, being apathetic and anergetic, and taking little
tenance of
MELANCHOLIA
361
and insufficient food, become more and more emaciand finally succumb to cardiac weakness or some infec-
exercise
ated,
tious or chronic disease.
The prognosis is less favorable in

cases occurring after fifty-five years of age.
In those cases that improve, but do not recover, the depres-
and the delusions gradually disappear, and the consciousness becomes perfectly clear, but the patients fail to
develop full interest in the surroundings and to adapt themselves to any kind of work. They are dull, sluggish, and
In those
indifferent, and tend to be low spirited and tearful.
delusions
fade
that become more demented the
very gradushow
fail
and
the
to
but
patients
gain insight
poverty of
ally,
and
are
entirely unable
forgetful, apathetic,
thought. They
sion
to apply themselves. They stand around stupidly or lament

Others develop the typical
in a monotonous fashion.
picture of senile dementia. Residuals of former delusions,
as well as a few hallucinations
and some expansive
ideas,
remain.
The
Treatment.
"
chief essential is the establishment of a
rest cure," which, first of all,
from
all
patients
nearest relatives, the
Hence
home
demands the removal
of the
including the
environment, and the customary
usually necessary to send the
deleterious
influences,
it is
occupation.
patient to a sanitarium or hospital.
urgent if suicidal tendencies develop.
This
is
particularly
It is necessary in most cases that the patients be confined

in bed with short intermissions, with sufficient and constant
the patient can be confined in bed out of

doors in a secluded, partially sheltered, and sunny place,
attendance.
If
be found decidedly beneficial. It aids in alleviating

insomnia and affords a more interesting and attractive
it
will
In very light cases a suitable change may be

found in removal to a different boarding-place or into the
environment.
362
associations of a happy family.

It is decidedly not advisable
to attempt such distractions as might be afforded by long
journeys, sight-seeing, and constant company. The rest in
bed should not be too prolonged; later it is best that it be

gradually replaced by short drives or walks, combined with
daily change of scenery.
Of next importance
is
Monotony
in diet should always be avoided
by consulting the
Careful regulation of the intestines,
tastes of the patient.
combined,
The food should be

and at frequent intervals.
nutrition.
nutritious, given in small quantities
if
necessary, with rectal injections, usually imExtreme anxiety and restlessness often
proves the appetite.
necessitate artificial feeding
by stomach or nasal tube
order to maintain nutrition.
When this is contraindicated by
cardiac weakness,
it is
Insomnia, which
to overcome,
is
is
in
necessary to resort to saline infusions.

both troublesome and often difficult
best combated at
first
by prolonged warm
baths in the early evening, warm packs, or gentle massage

provided it does not increase the agitation. Hot malted
milk before retiring
may
aid in inducing sleep.
These
measures, well carried out, often render hypnotics unnecessary, the use of which is always inadvisable because of the
prolonged course of the disease.

is
the most
Of the hypnotics, alcohol
Paraldehyde, one-half to one
useful.
fluid
trional in ten to fifteen grain doses, veronal seven
$ram,
and one-half
grains,
and somnos are the most
useful.
The
distressing condition of anxious restlessness may be

combated with opium. It is best given in rapidly increasing
doses beginning with five drops and reaching thirty to fifty

drops of the tincture of opium three times daily, which is
gradually reduced as soon as the restlessness begins to subside.

This drug sometimes not only fails, but serves to aggravate the symptoms,
when
it
must be withdrawn gradually.
MELANCHOLIA
Improvement from this source,
a few days.
careful,
if it is
Suicidal tendencies
363
to occur, appears within
necessitate
painstaking,
and constant watching, as melancholiacs are the most
thwart in their attempts at suicide. This care

must be as strenuously observed until recovery is well esdifficult to
tablished.
The psychical influence which may be constantly exerted

over the patients by those in attendance is of the greatest
value in alleviating distress, modifying the delusions, and
relieving the anxiety.
For
this reason the
manner should be
friendly, and assuring, and some attempts should

be
made to lead the thoughts of the patients away from
always
As the patients improve there should
their depressive ideas.
gentle,
be a systematic effort to gradually engage them in some

light
employment, as sewing, reading, writing,
from
relatives are always deleterious
disease
must be forbidden
Finally,
and
etc.
Visits
in the height of the
it is
of the
utmost im-
portance that the patients be kept under observation and

safe index of this
treatment until thoroughly recovered.
may
be found in their insight into the disease and the
return of normal sleep and nutrition.
PRESENILE DELUSIONAL INSANITY
B.
THERE
is
a small group of cases appearing during involu-
tion which are unlike either melancholia or senile dementia,
showing many of the characteristics of dementia praecox. It

has been tentatively differentiated and characterized by the
of marked impairment of judgment,
numerous
unsystematized delusions of susaccompanied by
picion and greatly increased emotional irritability.
gradual
development
Etiology.
The psychosis
is rare,
occurring only twelve

majority of the cases
times in ten years' experience. The

are women, in whom the disease appears between
to sixty-five years of age; while in
There seems to be
fiftieth year.
men
it
fifty-five
occurs about the
marked hereditary
pre-
disposition to the disease.
The onset of the disease is gradual,

Symptomatology.
with a change of disposition. The patients at first become
quiet,
discontented, moody, suspicious,

delusions gradually develop which at
seclusive,
Then
and
transitory, but
vague
ritable.
the
later
and
ir-
first
are
become more permanent and
appear are the hypochonpatients complain of the most varied

and changeable nervous sensations and pains, spasmodic
definite.
Among
driacal delusions.
first
to
The
twitchings, vertigo, troubled dreams, debility, malaise,

roaring in the ear, etc., which remind one of hysterical
complaints.
senseless,
These ideas
and the
later usually
become somewhat
patients complain that the spine
up, the brain shrunken,
all
strength has departed,

364
is
etc.
dried
365
Meanwhile, fantastic delusions of suspicion appear. The

patients claim that their clothing has been exchanged or
stolen; that articles of furniture have been removed and
others of less value substituted;
thieves are about.
They
suspect poison in the food; accuse the physician of trying

to get rid of them, of being obscene, of removing the womb,
or making them ill for the purpose of studying their case.
The husband believes that the wife is secretly dosing him.
Delusions of infidelity are usually very numerous and
prominent. The husband is accused of eying women on the
street, of flirting
servant,
with every one he meets, of caressing the

letters from the schoolmates of his
and receiving
He arranges to meet women whenever he leaves

and
has intercourse with every one possible. The
home,
husband is suspicious of his wife because she leaves him at
daughter.
night, or is surprised
when he
returns
home
unexpectedly.
they are
It is characteristic of all these delusions that
exceedingly unstable. They appear at one moment, are

abandoned in the next, and again recur in another form. As
regards insight, many patients admit that they might have
been mistaken and that they are
but they fail to really

appreciate the senselessness of their ideas. Half an hour
later you may find them in the greatest distress, because they
sick,
have been poisoned, or because some one has hidden under

the bed ; they are going to die, etc.
soothing word usually
suffices to quiet them and dispel their fear.
Hallucinations
accompany the delusions
in only a
few
The
patients are sometimes threatened, or hear

The cries
of intercourse with their wives.
boast
strangers
of their ill-treated children reach them.
At night they may
see dark forms stealing out of the room, or feel some one lying
cases.
beside their wives.
It is a noteworthy fact that the patients

do not make a genuine attempt to intercept these guilty
366
parties.
If
a search
is
instituted
and they
fail
to find
one, they express anger only because connubial fidelity

violated with such shamelessness and slyness in their
presence.
Consciousness
any
was
own
unclouded and orientation unimpaired.

coherent, but judgment shows a marked weakness,
is
Thought is
noted in the retention of the most fantastic delusions, while
the consciousness of the patient is perfectly clear. The
patients cannot see the senselessness of the delusions, and
while they may claim that they are open to conviction, they
can never be convinced. Their memory for remote events is
unimpaired.
they add
The
However, in the narration
all sorts of
of their delusions,
embellishments and misrepresentations.

one of depression and fear;
emotional attitude at first is
occasionally
it
leads
to
suicidal
attempts.
Later there
usually appear some excitement and irritability. The patients then talk a good deal, make verbose complaints, stir
up boisterous scenes, fly into violent passion, and are abusive,
but they are usually quieted without difficulty. They
sometimes laugh and cry without cause.
The conduct is characterized by all sorts of senseless
actions.
In accord with their delusions
many
patients run
about from one physician to another, and solicit much

advice without attempting to follow any of it. Some stop
eating, seclude themselves, destroy everything within reach,
and become violent. Jealousy leads to strict surveillance of
the husband or wife.
The servant
is
sent out in search of
them; torn letters in the waste basket are placed together in

order to obtain proof of guilt, and the supposed seducers may
be publicly accused.
With the advance of the disease the delusions become more
and children are

or suspended on a
senseless; the patients claim that the wife
being tortured, the son nailed to the
floor,
367
the wife wanders nightly from place to place, and

every one is talking about it. Female patients believe that
their husbands have intercourse with their own children, and
fence;
even with other men, disguised as women.
They
are aware
of this only through sensations in their own bodies, whenever they are deceived. The precious Lord proclaims
everything, talks to them, and lies beside them at night like a

shadow. Persons and the environment are changed; their
bodies are disfigured and influenced. For this reason, many
patients remain in seclusion, veil themselves, and at times
refuse to speak and then suddenly become very friendly and
These delusions frequently change, and

may temporarily fade away, although some general signs of
them are constantly recurring. In spite of progressing
communicative.
mental deterioration, the patients do not become incoherent.

Some regard these cases as paranoia, but they
Diagnosis.
from paranoia,
certainly differ
in that the delusions are not
The
systematized.
frequently, the
persecutors remain indefinite or change

suspected consorts are not regarded as
enemies, but are often thought to have been seduced. Moreover, the patients do not find in their delusions any broad
basis for action,
and except
for their occasional violent out-
breaks, do not treat the supposed persecutor as especially

they associate with their faithless wives, in fact
even force themselves into their company, and surprise one
hostile;
by becoming
just
friendly toward those persons
previously suspected and accused.
whom they
They
have
often prefer to
be confined in the hospital in spite of complaining of all sorts

of persecution, because they enjoy the protection afforded
them
there.
Finally, the delusions
do not continue
stable,
but change frequently, and sometimes even in a short time.

The conditions of excitement seem to depend less upon
deliberation than emotional vacillations.
368
Some
consider these cases of dementia prcecox, which
may
occur at this age, although not frequently. These patients

do not present catatonic symptoms. The peculiar resistiveness and excitement occasionally manifested are not compulsive or spontaneous, but depend upon delusions or
moods.
The
become apathetic rapidly, but,

continue irritable and interested, while
patients do not
on the contrary,
disturbances of judgment greatly predominate over those of

the emotions and actions.
Prognosis.
The outcome
is
never
characterized
by
profound dementia or confusion of speech, but by a moderate

deterioration, with isolated, changeable, and incoherent
delusions.
Recoveries or marked improvements are not
likely to occur.
Treatment.
The
treatment
is
wholly
symptomatic.
Most patients are troublesome and need hospital treatment,

but some, under favorable conditions, are able to remain at
home.
SENILE DEMENTIA 1
0.
SENILE DEMENTIA
is
characterized by
a gradually progres-
sive mental deterioration, occurring during the period of in-
volution
and accompanied by a
nervous system.
series of lesions in the central
comprises several groups of cases, in-
It
and severer
cluding simple senile deterioration of lighter

grades, presbyophrenia,
sional insanity.
The
Etiology.
involution,
sixty
and
senile
disease
delirium,
may appear
at
and
senile
delu-
any time during
encountered most frequently between

Individuals with a
seventy-five years of age.
but
is
endowment, worn with hardships, and

may succumb before
Men
who
have
been
more
sixty.
exposed to overwork and
excesses develop the disease earlier than women. Defecfaulty constitutional
especially those addicted to excesses,
tive heredity occurs in
about
fifty
per cent, of cases, but
is
mostly to senile deterioration in parents and in
confined
brothers and
Very frequently the disease develops

immediately following an injury, particularly head injury,
sisters.
shocks, also acute

influenza and bronchitis.
emotional
Fuerstner, Archiv
Senilis, Diss. Zuerich,
f.
Psychiatric,
febrile
XX,
diseases,
Uber Dementia
Noetzli,
1895; Alzheimer, Monatsschrift
Wiener Klinik,
especially
f.
XXV,
Psychiatric u.
u. 10, 1899;
Annali di Neurologia, 1899, 6; Zingerle, Jahrb. f. Psychiatric,
XVIII, 256. Pickett, The Jour, of Nervous and Mental Disease, 1904,
Neurologie, 1898, 101;
Scholoess,
Colella,
p. 81.
2B
369
370
All
advanced cases of
senile
dementia present, both macroscopically and microscopically,

atrophy of the nerve substance. The brain weight is from
two hundred to
may
five
hundred grams below normal.
There
be compensatory thickening of the cranium, and in-
crease of the cerebrospinal fluid (hydrocephalus ex-vacuo).

The Pacis usually adherent to the calvarium.
The dura
chionian granulations are increased in size. Pachymeningitis interna hsemorrhagica is often present, and sometimes
to
an extreme degree.
uniformly
over
the
The pia
entire
is
cortex,
somewhat thickened
may
contain
many
corpora amylacea, and is almost always edematous. The

convolutions are narrow and shrunken, and the gaping
Minute
fissures contain blebs filled with serous fluid.
hemorrhages are sometimes found in the cortex, corona
and basal ganglia. The ventricles are much dilated

and ependymal walls thickened, and occasionally granular.
The choroid plexuses usually present various stages of cystic
The cerebral vessels exhibit arteriosclerosis,
degeneration.
in which there are often evidences of hyaline changes, but it is
more characteristic of the vessels in senile dementia to show a
rich pigmentation of the endothelial and adventitial cells.
The fact that the blood vessels, in simple senile deterioration,
radialis,
are only moderately involved, favors the view that the

vascular changes in senile dementia cannot be regarded as
the particular cause of the disease. Further proof of this is
found in the fact that there are

sive vascular lesions of the
of senile dementia.
vascular
lesions
many individuals with extenbrain who do not exhibit signs
Nevertheless,
more or
commonly accompany
less extensive,
senile
dementia.
There occasionally occur combined forms of senile and

"
senile dearteriosclerotic insanity, called by Alzheimer
cay"
(see p. 334).
SENILE DEMENTIA
371
Microscopically, the nerve cells present different grades

of the chronic cell change in addition to much pigmentation.
Complicating the chronic
cell
change there
may
occur any of
changes described in paresis (see p. 282).

Both the tangential and radical fibre tracts in the corona
those acute
cell
present more or less atrophy. The neuroglia cells are more

numerous and show an increase in the number of nuclei,
the
cell
bodies often forming distinct clumps (raseri) with a
thick network of fine glia fibrils. Many of the neuroglia cells

show evidences of extensive degenerative processes; such as,
marked pigmentation, and atrophy of the

The spinal cord presents an atrophy in its ganglion
vacuolization,
nucleus.
cells
and
fibre tracts.
Calcareous placques are sometimes
The entire pathological picture, however,

pia.
as
well
as
the
clinical picture, but as yet it is impossible
varies,
to establish any definite relationship between the different
found in the
pathological and clinical pictures.

The other organs of the body present senile atrophy and
arteriosclerotic changes.
The condition of the heart, with
chronic endocarditis and fibroid changes in the myocardium,

is of importance, as it interferes with cerebral circulation.
Symptomatology.: The apprehension of external impressions is slow and difficult. The patients fail to note
and to understand the connection of things that are

complicated. They, therefore, become easily disoriented,
cannot see the point in a discussion, and overlook important
matters. They are drowsy, disinclined to think, somewhat
dazed, and easily lose the thread of a conversation.
Thought
becomes stagnant and the patients are unable to change their
viewpoints or to gain new ones. The old trains of thought,
details
being inaccessible to new ideas, do not get beyond the beaten

paths.
Ideas, once aroused, are constantly recurring, without any regard for the circumstances.
The mental
elabora-
372
tion of external impressions, the consideration of cause and

effect, and the critical examination of ideas is always in-
adequate and uncertain.
This
explains
comprehend the views and
total inability to
the
patients
conditions of
others, as well as the inflexibility of their opinions
and
their
Their delusional ideas

susceptibility to delusional ideas.
consist mostly of excessive fear of illness, senseless distrust,
or childish egoism. Other prominent delusions are those of
and robbery. They commonly believe that many

are
done to annoy them and that their property has
things
lack of genuine insight into
been taken from them.
reference
their infirmity, necessitating the
appointment of a trustee
or
conservator, creates still other ideas of persecution.

Hallucinations and especially illusions are common.
The
failure of
especially
memory
memory
is
always a prominent symptom,

Present and passing
for recent events.
time seem to be completely effaced

from memory. Patients forget where they were yesterday, or
where they have placed things, do not realize that they are
relating the same story that they told yesterday or perhaps a
few hours ago, cannot recall the names of recent acquaintOn the
ances, and even forget the names of old friends.
events, within a short
other hand,
memory
and furnishes the
for events of early life
is
well retained
chief topics for conversation.
The gaps
are very often made good by extensive

fabrications.
Finally, as the result of the progressive impairment of memory, to which nothing new is ever added, there
of recent
memory
develops an increasing impoverishment of the store of ideas,

with an extraordinary dearth and uniformity of the content
of thought.
and lack of sympathy

are the prominent characteristics. The patients become
apathetic; they fail to enter into the sorrows and joys of
In emotional
attitude, indifference
SENILE DEMENTIA
373
those about them, and do not grieve at the loss of friends.

Self-interest, with the gratification of personal whims, precedes everything. They are no longer interested in their
family or home. This may advance to genuine avarice, the
overwhelming even filial affection. The

fundamental emotional tone is sometimes that of surly disfeeling of greed
satisfaction,
and
at others a
exalted self-confidence.
There
childish
happiness and an
be
irritability for short
may
The patients
are inconsiderate, arbitrary, dogmatic,

periods.
and offended at any opposition. The emotional states are
both superficial and transitory; extreme and tearful sympathy or silly happiness may be aroused on the slightest pre-
and
The
sexual feelings are

frequently increased, impelling the patients to enter into
improper sexual relations, especially with children ; to use
text
just as rapidly disappear.
obscene language, to dress in an attractive manner, plan

marriages, and in extreme conditions to expose themselves.
The
conduct of the patients varies greatly.
Many remain
and contented, and, in spite of increasing deno trouble and can be kept at home. Other
cause
mentia,
quiet, orderly,
an increasing restlessness: they

abuse
those about them at every opgrumble, quarrel, curse,
patients gradually develop
and often threaten and become
aggressive. Many
to
in
to
patients begin
excesses,
masturbate, to wander
idulge
away from home, to make foolish purchases and plans, to
hoard all sorts of plunder, and ultimately get themselves into
portunity,
many
difficulties.
teristic.
But nocturnal
restlessness is
It consists in getting out of
and
most charac-
dishevelling the
bed, wandering about the house with a light, and rummaging

chests and closets without evident purpose.
During the day
these patients are weary and drowsy and frequently fall to
Patients are unable to
sleep during conversation and meals.
care for themselves properly and are dirty about their clothing.
374
Physical Symptoms.
is
In addition to the insomnia, there
usually a pronounced deterioration in the general physique

The patients usually look older than
and some anorexia.
they really are, the musculature is reduced, and the strength

below par. A fine tremor is characteristic of the senile, and
can be distinguished from the tremor of the paretic and the
by the numerous
irregularities in the separate

there
are
a series of physical sympstrokes.
Furthermore,
toms corresponding to the cortical lesions; namely, headache,
alcoholic
vertigo,
convulsive seizures with transitory or permanent
aphasic symptoms, hemiansesthesias, hemianopsia, ptosis,

hemiparesis of the muscles of the eye, tongue, or extremities.
The
pupils are sometimes small, or unequal, and react slugThe reflexes are usually increased,
gishly or not at all.
seldom
diminished.
The
speech
is
often
indistinct.
Neuritic disturbances are frequent. Finally, evidences of

arteriosclerosis are frequently observed.
In the severer grade of senile dementia there develops great

clouding of consciousness and complete disorientation. These
patients apprehend what is said to them and respond briefly
in a sensible manner, but they are wholly unable to grasp
what is taking place about them. They have no idea of

where they are, address their associates by the names of
friends long since dead, and even fail to recognize their
relatives.
They have very little memory for what occurs in
their daily lives, and gradually lose even their remote knowledge. They cannot tell how old they are, or how many
children they have. They say they are twenty-five years of
age, have
had twenty-five
children, the oldest of
twenty-five years, that they
pregnant. They undress at

call the physician by their husbands' names.
easily distracted
which
is
menstruate, and are now

midday, thinking it night, and
still
They are
and cannot hold long to one thought.
SENILE DEMENTIA
375
The store of ideas is greatly impoverished and the same remarks are repeated over and over again. They occasionally
indulge in a peculiar senseless rhyming and a half-singing
repetition of words and syllables.
Numerous changing fantastic delusions are present, both
depressive and expansive, and often also hypochondriacal
and nihilistic. They cannot speak, eat, or sleep; nothing has
passed their bowels in weeks, and the liver has rotted away.
They have leaned against a radiator and burned a hole in the
lungs which has caused the heart to cease beating. Their
abdomens have been cut open and organs removed, or they
will be buried alive.
On the other hand, they may claim
that they possess much property, hold an important position,
or are in communication with God. The delusions are apt to
be
embellished
with
numerous
fabrications.
Hallucina-
and hearing are frequently present.

The emotional attitude varies. The patients are sometimes
apprehensive and dejected, sometimes irritable, and at others,
elated and happy, while rapid changes from one mood to
another are common. In actions they display more or less
restless activity, which is especially marked at night.
They
regularly tear and throw about their bedding, creep about the
room, picking into the corners, destroying and smearing
their clothing, or they laugh, sing, and run about in a silly
manner. They are very untidy, and wholly incapable of
caring for themselves. Insomnia is pronounced, and very
tions of sight
little
nourishment
is
taken.
In the group of cases of senile dementia called presbyophrenia, the patients, in spite of a marked disturbance of
the impressibility of
memory, retain fairly well their mental

and to a certain extent, also,
alertness, the coherence of thought,
good judgment. Women predominate in this group, and

chiefly robust individuals are affected.
Usually the disease
376
develops gradually, sometimes following more or less definite
prodromal symptoms which have been in existence for some

weeks. It may appear as an episode during the course of
simple senile deterioration.
The patients are capable

tion, and of comprehending
of entering into a long conversa-
in great
measure the occurrences
in their environment, but they utterly fail in obtaining
any
conception of their own condition or of their relation to the

environment. They forget almost immediately what they
have been doing or what they have heard.

casional impression
is
retained,
and
Only an oc-
especially those ac-
companied by some
orientation
is
Place and, particularly, time

feeling.
disturbed.
Patients cannot tell where they are
or those about them.
strangers as acquaintances ;
regretting that they cannot just recall the name, but they are
confident that they have seen them before. They know
They greet
neither the day nor the week. They make all sorts of contradictory statements as to their age, speak as if their parents
were still living, and refer to their own infant children. The
Their ability to reckon may

be fairly well retained, as well as knowledge of the small
affairs of daily life, like the price of articles of food, cooking
store of
knowledge also
is
faulty.
beyond that is lost. They cannot recall

and geographical facts, the name of the President,
and, indeed, sometimes even the names and ages of their own
receipts, etc., but all
historical
children, but yet they

facts, as their
may
be able to recall a few remote
own maiden name and
the playmates of their
childhood.
The
patients do not appreciate these
marked
defects.
When quizzed, they will explain their inability to answer such

questions by the fact that they were never interested in such
things, that women are not supposed to bother about such
matters, etc.
They usually make good the
lapses in their
SENILE DEMENTIA
recent memories
by simple
fabrications;
377
such
as, that
they
were busy in the morning, had been out to call on their
parents, other relatives were there, and they all drank some
Now they have come here to help with some work,

but are soon going to return to their place of employment,
coffee.
where they are earning good wages. These patients rarely

express delusions or have hallucinations.
Their judgment
their early
is fairly
knowledge and
well retained as far as

facts
it
involves
which are at their disposal.
"
For instance, such senseless expressions as that the snow
black," or
"
that ball
is
is
square" cause them to smile, and
they become indignant if told that they steal or perjure themselves.

On the other hand, the patients fail to recognize the
most absurd contradictions as regards the temporal relation

of events, even when their attention is called to them. They
will say that their parents are no older than they, that their
daughter is only three years younger, though she was born
more than ten years ago. In their conversation the patients
are often energetic and loquacious, although they frequently
digress.
The
emotional attitude of the patients is usually that of

happiness with an occasional brief show of peevishness or
They exhibit an interest and readily familiarize
irritability.
themselves with their environment and can appreciate a joke.

In conduct they are, in general, orderly, and busy themselves
in one
way
paralysis
Occasionally there is some nocturnal

Symptoms of severe brain lesions, particularly
or another.
restlessness.
and apoplectic
attacks, are rarely encountered.
This picture of presbyophrenia
a number of years. Again

simple stupid dementia.
Senile Delirium.
acute onset
and a
it
may persist unchanged for

may pass over into a state of
This form
is
characterized by
a more
short course with great clouding of conscious-
378
active hallucinations,
and
delirious conduct.
It often
appears as an episode in the course of senile deterioration;

indeed, signs of beginning senile dementia usually precede
the outbreak.
Exciting causes are prominent; such as
acute illnesses, mental shock, or injuries.
The patients rapidly develop many hallucinations of sight

and hearing. They hear voices, threats, singing, see the
devil, or crowds of men pressing upon them with knives.
They are anxious and restless, claiming that they are in the
world below, surrounded by mighty powers, are bewitched
and poisoned, the house is being flooded and huge boulders
Disorientation is complete. The
rolled about the room.
speech
is
irrelevant, incoherent,
and
flighty,
and
is
often
limited to unintelligible, disjointed words, or to a repetition

There is usually great pressure of
of senseless syllables.
The activity is greatly increased; they rattle doors

and windows, shout for help, refuse food, resist, tear up the
bedding, and crawl about the floor, etc. Insomnia is
speech.
extreme.
The
course of the delirium presents
sudden remissions, with more or

consciousness.
interval, or
peevishness,
less
The delirium may
many
fluctuations
and
complete return to clear

reappear after a short
may pass over into a state of anxiety with

which may persist, or in time entirely disappear.
it
In unfavorable cases the delirium becomes extreme, leading

to collapse and death from exhaustion, injuries, or acute
febrile diseases.
Finally, there is a characteristic group of cases in senile

dementia which has been called senile delusional insanity.
These cases develop gradually.
become retisoon becomes apparent
The
patients
and suspicious. It
are
dominated
that they
by delusions ; that they believe that
they are being robbed, are being ridiculed and insulted by
cent, irritable,
SENILE DEMENTIA
their neighbors,
is
and are hindered in
being placed in their food.
379
their
work
that poison
These delusions are ap;
parently scanty, somewhat incoherent, and are rarely elaborated, though they may remain unchanged a long time.
Hallucinations are often present, especially in deaf patients.
The
patients remain completely oriented.

However, persons in the environment, who are involved in their delusions,
may be mistaken for others. The emotional attitude usually
becomes indifferent, though occasionally the patients are irriand egotistical. In conduct they are orderly and tract-
table
able; they busy themselves
Diagnosis.
normal
and only occasionally are
The
senility,
excited.
common
to
physiological
changes
such as the defect in the impressibility of
memory, an impoverishment
of the store of ideas,
an emo-
tional indifference, a paralysis of activity, and the development of stubborn unruliness, renders very difficult the
differentiation of the milder
certain
extent this
forms of senile dementia.
distinction
is
To a
The
wholly arbitrary.
appearance of delusions and of excitement should leave no
doubt as to the presence of a psychosis. The depressive
states in senile dementia may be differentiated from melancholia by the dearth and the incoherence of the delusions and
the defective
The
memory and emotional
differentiation of senile
dulness.
dementia from
arteriosclerotic
has already been indicated that focal

insanity
symptoms of themselves are not particularly characteristic
of senile dementia, and point only to the fact that there is
is difficult.
It
an accompanying vascular
prominent such symptoms
Therefore, the more

the
are,
greater the role of
arteriosclerotic changes.
Inversely, a rapid and general
of
the
mental
decay
activity, particularly a severe disorder
of
memory,
disease.
indicates senile dementia.
tion holds true in syphilitic insanity, in
The same observawhich the dementia
380
never becomes very pronounced until after a long duration,

while hallucinations and delusions are more prominent.
The senile delirium, except for the underlying basis of
deterioration, does not differ
from the delirium encountered
in other psychoses.
wholly symptomatic. The

condition of faulty nutrition needs careful watching in order
to secure the ingestion of a sufficient amount of easily diTreatment.
The treatment
The insomnia
gested food.
is
of the senile is
most
intractable.
employ the simplest remeit,

the
time the patient awakes
dies; as, warm nourishment at
after the sleep of the early night, prolonged warm baths, and
In combating
sufficiently
one should
warm bed
hot-water bottles.
first
clothing, together with,
Warm
if
necessary,
packs should be employed most
Of the hypnotic remedies, alcohol is most useful.

Paraldehyde, chloralamide, and somnos are at times also
efficient.
Occasionally small and repeated doses of nitroglycerin give excellent results. These patients, if kept at
home, must be watched closely at night, and placed in rooms
without lights and with guarded windows in order to prevent
injuries to self and danger from fire to others. If the insomnia and restlessness become extreme, the prolonged warm
cautiously.
bath (see
p. 140)
may
be used.
Failing in this, one should
improvise a padded room or a bed with high padded sides.

In the cases accompanied by great anxiety, opium (see p. 362)
is
indicated
and often brings the desired
relief.
IX.
MANIC-DEPRESSIVE INSANITY 1
MANIC-DEPRESSIVE insanity is characterized by

groups of mental symptoms throughout the
dividual, not leading to mental deterioration.
the recurrence
in-
of
life of the
of
to
These groups
be termed the
mixed phases
of the disease.
symptoms are
manic,
sufficiently
the depressive,
and
well defined
the
The chief symptoms usually appearing in the manic phase

are: psychomotor excitement with pressure of activity, flight
ideas,
of
distractibUity,
In
tional attitude.
psychomotor
the
retardation,
and happy though unstable emodepressive phase we expect to find

absence
spontaneous
of
activity,
and depressed emotional attitude; white the

mixed phase consist of various combinations
the
symptoms of
of the symptoms characteristic of both the manic and depres-
dearth of ideas,
sive phases.
Etiology.
Manic-depressive insanity
is
one of the most
prominent forms of mental disease, and comprises from,

twelve to twenty per cent, of admissions to insane hospitals.
Of the
etiological factors, defective heredity is the
most im-
portant, occurring in from seventy to eighty per cent, of

1
Kirn, Die periodischen Psychosen, 1878

Mendel, Die Manie, eine
Pick,
Emmerich, Schmidt's Jahrbucher, CXC, 2
Monographic, 1881
Circulates Irresein, Eulenburgs Realencyclopsedie, 2. Auflage; Hoche,
Ueber die leichteren Formen des periodischen Irreseins, 1897; Hecke,
Zeitschrift fur praktische Aertze, 1898, 1
Pilcz, Die periodischen Geistesstorungen, 1901; Thalbitzer, Den manio-depressive Psykose, Stem;
mingssindsygdom, 1902;
Hoch, Ref. Hand. Med.

381
Soc., Vol. V, 120.
382
The
cases.
of disease.
relatives
The
have often suffered from the same form
defective constitutional basis
is
often ap-
parent in individuals previous to the onset of the psychosis;
some are peculiar, some are abnormally bright, others are

of an excitable disposition and subject to frequent and apparently causeless changes of mood, and still others are excessively shy and reserved; while a few are imbecile from birth.
Physical stigmata
in the disease
The
may also be present.
Women predominate
and represent about two-thirds
of the patients.
disease almost always appears independently of exterIn a few cases the appearance of the first
nal causes.
attack
is
coincident with the
and
attacks
first
menstruation.
The
first
occur
subsequent
may
during succeeding
periods of childbearing, but it is also a conspicuous fact that
the attacks do not cease at the climacterium. In twothirds of the cases the first attack appears before twenty-five
years of age, and in less than ten per cent, after the fortieth year, in
both of which periods
women
greatly predomias ten years of
The first attack may occur as early

age, and as late as seventy years.
The nature of manic-depressive insanity
nate.
is still
obscure.
Several hypotheses have been formulated, but none are adequate. There are no demonstrable anatomical, pathological
lesions characteristic of this disease.
Apprehension of external impressions

Symptomatology.
in the manic states, with the exception of hypomania, is
more or less disturbed.
This disturbance
is
due largely to the
great distractibility of attention. The patients lose the

ability to select and elaborate their impressions, because each
striking sensory stimulus forces itself upon them so strongly
that
it
absorbs their entire attention.
is
may
holding objects before them, but

distracted
quickly
by something else. Hence, the
be held for a
it
moment by
Their attention
MANIC-DEPRESSIVE INSANITY
383
environment is never fully apprehended, and the picture

remains disconnected and incomplete, although there is no
In the depressive
serious disorder of the perceptive process.
forms
apprehension
disturbed;
especially
is
is
more manifestly and extensively

this true in stupor.
Even
in the
lighter depressive states the patients are unable to elaborate
and comprehend
well their impressions.

Consciousness is regularly disturbed in the severer forms
of the disease.
At the height
of
the manic excitement
Patients
hazy impressions lead to disorientation.
do not correctly understand where they are, mistake persons,
the
and greet the physicians and nurses by the names
of relatives
This mistaking of persons sometimes arises

from slight similarities of dress or facial expression, but at
other times it seems to be due altogether to the capriciousor neighbors.
ness of the patients. In the less severe manic forms consciousness is very slightly disturbed. On the other hand, in
the depressive states of the disease consciousness

clouded, particularly in the stuporous conditions.
is
more
Hallucinations are rare, except in the delirious form of

the manic phase, and in the more marked stuporous depressive conditions, but even here they are neither a prominent
nor persistent feature. Furthermore, the hallucinations

do not have the same sensory distinctness common to the
sense deceptions of dementia prsecox. On the other hand,
numerous and varied
false sensations often
accompany the
pronounced hypochondriacal fears of the depressive patients.

These are experienced all over the body. Patients claim
that they feel the food as
they
solving,
skin,
courses through the veins, that

organs being consumed, that nerves are disthat little white worms are crawling under the
it
feel their
and
etc.
This
processes of the
increased
sensitiveness
body stands out
to
the
internal
in contrast to the loss of
384
manic
manic
to hunger, and to
central sensitiveness to external impressions in the

states, as seen in the remarkable insensibility of the
patients to extremes of heat
and
cold,
pain.
Memory
does not suffer
although patients
over their store of ideas.
itself,
much
injury from the disease

often temporarily lose control
Especially in the depressive

states the patients are often unable to recall even simple
It takes them a very long time to solve a simple
facts.
relate some experience.
During the disease
is
It has
the
process
impressibility of memory
impaired.
been shown by special tests that manic patients make more
problem or to
than normal individuals in recalling to memory their

perceptions. There is sometimes a tendency to fabricaerrors
and to depict grotesque experiences. Memory for

events of the attack is usually somewhat indistinct, partions
ticularly
where there has been pronounced excitement or
profound stupor.
Delusions are often present in manic-depressive insanity.
In the manic phases they are changeable and frequently
appear in the form of playful boasts and exaggerations.

Where the consciousness is -somewhat clouded, the patients
tend to elaborate more permanent expansive and persecutory delusions, the latter being directed particularly against
the family; also delusions of jealousy and poisoning.
In the depressive states hypochondriacal ideas are most
prominent, and are often associated with delusions of persecution and of self-accusation. The depressive delusions
sometimes beome markedly

expressed
by
pare tics.
fantastic,
Patients
to
those
express
some
similar
usually
they appreciate having undergone a change, but

are
they
quite apt to attribute it to misfortune or abuse of
some sort, rather than to mental illness.
insight;
385
Disturbances of thought are prominent symptoms. In

the manic states a definite line of thought cannot be followed
out; ideas pass abruptly from one subject to another, and

the line of discourse is lost in a mass of detail. A short
question
may
be answered correctly, but with the addition

and side remarks that have only a distant
of a host of details
It is impossible
relation to the subject
circumstantiality.
for the patients to relate any event coherently without
frequent inquiries and suggestions on the part of the listener

to recall him from his digressions. There is a lack of voluntary
guidance of the train of thought
hence there are abrupt
changes in the succession of ideas influenced
by objects that
or by sounds caught
happen to come into the field of vision,

up from the surroundings. On the whole, there is a multitude of ideas which are not well connected. There is
no controlling goal idea. The association of ideas follows
along accustomed tracks, especially those that play an
important part in daily expressions; such as bits of slang
and common phrases. The resulting incoherence of thought
Observation of
gives rise to the so-called flight of ideas.
external objects
plete,
may seem
but in reality
tracts the attention,
it is
is
to be very accurate
superficial.
and com-
striking object atstarts a train of
apprehended, and
thought, but before this has proceeded far something else

obtrudes upon the sensorium, and another is started. In
thought is delayed. Instead

an acceleration of the train of ideas, there is only flightiness
and an instability. There is an abundance of words, not
spite of appearances, genuine
of
of ideas.
Sometimes
in the depressive forms there
is
slight degree of flight of ideas.
As a counterpart
of
thought,
to flight of ideas,
we have
retardation
which regularly accompanies the depressive
phases of the disease, and also some of the manic-stuporous

2c
386
states
and the forms
of
manic excitement
allied to
them.
Patients seem unable to marshal their ideas, and are often

painfully aware of this. The individual ideas seem to develop
slowly and only after very strong stimuli. Hence, external
impressions do not quickly and easily arouse a group of
associations, but the train of thought has to progress slowly
and requires an especial effort of the will. On the other

hand, an idea once developed is not pushed aside by the appearance of new ideas, but it fades slowly and often sticks
with great persistency, especially if it arises in connection
with some feeling. Thus there result great difficulty and
slowness of thought, monosyllabic answers to simple quesThis is apt to be regarded as
tions, and a dearth of ideas.
evidence of dementia, until close observation demonstrates
that there
is
no
real deterioration.
The emotional attitude in the manic forms shows more or

There is a feeling of wellless elation and happiness.
being with a tendency to joke and to make facetious remarks.
Irritability is
Expressions of emotion are unrestrained.
prominent, giving rise at times to outbursts of anger from
trivial causes, but rapid changes in the emotional attitude
are
still
become
more
characteristic:
tearful,
in the midst of joy patients
and complain
of abuse
and misfortune;
again, in spite of profound misery, they may burst out into

boisterous laughter. These varying states appear and
disappear with the greatest rapidity.
Depression of spirits
sometimes appears for a few hours at a time during manic

states.
In the depressive states of the disease the emotional
regularly that of gloominess, despair, doubt, and
anxiety. Patients complain particularly of the loss of in"
"
terest in things;
they
everything is the same to them,"
"
are desolate and empty,"
they are dead, because they
attitude
is
have no feeling," " music does not sound natural," and
387
"
the crying of the children no longer creates sympathy."

They feel as if they no longer belong to this world. One
sometimes encounters moments when patients exhibit feeble
attempts at laughter and even brief gayety.
There are
some cases of simple retardation in which there is no especial emotional tone. In the transition states and mixed
phases there is stupor with silent mirth, or restless mischievousness with anxiety.
The disturbances found in the psychomotor sphere are
prominent symptoms. In the manic states the increased
facility for
the conveyance of stimuli into action gives rise

Every sort of impulse leads to an
to pressure of activity.
action, completely inhibiting all
or even
if
a volitional action
normal volitional impulses,

begun, it is overwhelmed
is
accomplished. Furthermore, almost imperceptible impulses excite the greatest variety of movements,
which are executed with unusual energy. In the mildest
before
half
manic states there appears a characteristic busyness and

an excessive display of energy over trifles. If the disease is
more severe, the actions become disconnected, and new
impulses intrude before any one object can be accomplished.
In the severest excitement, the actions change as rapidly
as the ideas.
The
actions, however,
depend upon and bear
a definite relation to the ideas and emotions.

of the
motor excitement
and depends
largely
is
The
due to an increased
upon external
stimuli,
intensity
irritability
the removal
which reduces the
Unrestrained activity tends

activity.
to increase the excitement.
The ready release of the motor
of
impulses perhaps accounts for the unusual absence of fatigue.

In these conditions excitement may persist for weeks or
even months without any signs of exhaustion.
The psychomotor pressure of activity is prominent also

and aids in the production of, flight of
in the field of speech,
388
ideas.
The easily aroused motor-speech dispositions have
a stronger influence in directing the train of thought than
the ideas arising from purely intellective processes. Instead of a logical sequence of ideas, we find that motor
coordinations determine their succession; thus, we encounter
those associations common in the everyday life; such as,
and rhymes, and finally a predominance

sound associations, when are heard such productions
"
Sam, jam, bang, slam, hell, shell, bells," etc. Silence
set phrases, slang,
of pure
as,
impossible. The patients prattle away and shout at the

top of their voices, scream, declaim with many gestures and
in a pompous manner, perhaps ending in unrestrained
is
laughter, or they sing, now softly, now slowly.

lowing is a sample of the manic production:
The
fol-
" I
was looking at you, the sweet voice, that does not want
sweet soap. You always work Harvard, for the hardware store.
Here is the right hand, the hand that they shot off yesterday.
The love of God don't win gray hairs. I don't care if I am nine-
my father taught me to love. Neatness of feet don't win

but feet win the neatness of men. Run don't run west, but
west runs east. I like west strawberries best. Rebels don't shoot
For three years I got over seven dollars a month
devils at night.
and some old rags. Take your time and be not disobedient, be
God's laws are all right, but
grateful when judgment day comes.
Royal Baking Powder is compressed yeast. Women should never
chew gum. Women should never smoke. Women should mind
their own business.
Fish-hooks are between the American flag,
You must pay for your own
red, white, and blue, Fourth of July.
I
am
no
Prudence.
tobacco
fiddler,
chewer, I am no street walker,
I am vaccinated, but McKinley does not win.
My father is a
Democrat. He had no work for three years."
teen,
feet,
Such incoherence
is
not the outcome of an excessive
repletion of ideas, but results from an inability to give

normal individual, at
direction to the train of ideas.
times,
389
might give expression to a similar production
if
he
could utter a sequence of ideas as they came into his mind.

In the disease picture this ideomotor excitability regularly
leads to the expression of every idea that presents itself.
The letter- writing of manic patients shows with equal
Single phrases and sentences may be well started, but are soon resolved into a
senseless enumeration of catch phrases, bits of slang, and
clearness the
same disturbance.
and bold, while underlining,

overwriting, and punctuation marks predominate.
The psychomotor field in the depressive form presents
a retardation of activity, due to the slowness of conversion
In the
of sensory and ideational stimuli into impulses.
The
rhyme.
script is coarse
mildest degree this retardation appears as a deficiency in

the power of resolution. Actions may not only be performed
slowly, but even after being started
may fail
of completion.
and talking, are

and
without
energy. Unless extreme,
performed very slowly
the retardation may be overcome by an emotional excitement, such as impending danger or some unusual stimulus.
The
simplest movements, such as walking
In the severest forms the retardation leads to a complete

abolition of all voluntary movements, producing a condition
of stupor, when the patients are unable to leave the bed or
attend to their physical needs.

Retardation may vary considerably in the extent to
which
tivity.
influences the different spheres of voluntary acThe patients may perhaps be able to dress them-
it
and
employ themselves without difficulty, but

from
any act that demands resolution. Some
they shrink
patients are so taciturn and monosyllabic that it is impossible to engage them in conversation, and although they
selves
to
are able to count or read aloud as rapidly as ever, they will

sit for hours with a letter in front of them, unable to finish
390
Again there are patients who read rapidly, but

line; and there are others who write long
letters, but become speechless as soon as you address them.
The symptoms enumerated above portray the disease
writing
it.
cannot write a
picture as a whole. As already indicated, these symptoms

tend to arrange themselves into two large groups, representing the manic and the depressive phases of the disease,
and a third smaller group, the mixed phase.
Occasionally,
to present sufficiently clear pictures to
permit their definite assignment to any one of these phases,
which condition, together with the occurrence of numerous
individual cases
fail
transition stages from one phase to another, emphasizes

the fact that it is impossible to draw a distinct border
line
between the prominent phases of the
disease.
MANIC STATES
The manic
states
comprise
hypomania, mania, and
delirious mania.
Hypomania represents the mildest form of the manic

"
mania mitis,"
states, and has been variously designated
"
"
folie raisonnante."
or
mitissima," and
Consciousness, apprehension, and memory are undisturbed.
The activity of the mind and of the attention is often increased; indeed, the patients may appear brighter and
clearer minded than usual, because of their ability to grasp
but in reality they cannot make use of
any valid comparisons. In the realm of ideation they show
a moderate flight of ideas, which is more especially noticed
in letters. They shift abruptly from one subject to another,
faint resemblances,
and are quite unable

sion.
They are very
being centered about
and
difficulties.
to bring a thought to a logical conclutalkative, the content of conversation

commonplace affairs, their experiences
They
revel in
minute
details,
and often
distort the facts with exaggerations
and frequent misrepre-
In the severer grades there
sentations.
of coherence in the train of thought.
391
is
a striking lack
The patients are unable
to arrange logically a series of ideas without abrupt transiIn their writings and
tions from one subject to another.
rhymes they often develop a flight of ideas. Upon effort
they may be able, for short periods, to gain the mastery over
their incoherent thoughts, as well as over their excessive
There
activity.
may
occur, for short periods,
more marked
excitement and dazedness.
Memory
for recent events is not always correct.
in their conversation are easily carried
Patients
away with exaggera-
and
distortions, which arise in part from their keener

perception and in part from accessory interpretations,
tions
which never really come clearly into consciousness. Although

there are no genuine delusions, yet there is a greatly exaggerated self-esteem. Patients boast of their own deeds
and show a proportionate lack of appreciation for those of
they lack insight into their condition.

While they may admit a previous attack, they cannot regard
their present state as anything but normal.
They justify
others.
Hence,
their actions in a
ible excuses.
most persistent way, and never lack plaus-
Moreover, they believe themselves misjudged
or falsely confined, as they never were
more healthy or
capable of work. Usually, in their estimation, the relatives

friends, or those who have been instrumental in their
and
confinement, are the ones in need of treatment.

As to the emotional attitude the patients are usually elated,
happy, cheerful, and often exuberant. They derive great
and undertakings. Some

patients develop a pronounced humorous vein and a tenpleasure from their associations
dency to see the funny side of things, to make facetious

remarks, to invent nicknames, and to make sport of them-
392
selves
and
others.
tinctly selfish,
On
They
while their
the other hand,
and friendly, but disand wishes prevail.
are jovial
own
desires
increased irritability
may
develop,
when the
patients become discontented, intolerant, and

quarrelsome with their environment. They are apt to
become inconsiderate, saucy, and rude, whenever any one
opposes them.
fits
of anger
Insignificant occasions
and even
aggressiveness.
may
lead to violent
They
are completely
under the control of sudden impressions and emotions,

which quickly acquire an irresistible power over them.
Their general conduct bears the stamp of impulsiveness
and rashness; hence, on account of the slight disturbance
of intellect, their conduct is often regarded as unscrupulous.
The most
striking
symptom
The
of all
is
the increased psycho-
patients
compelled to be doing
something all the time. They must take part in whatever
goes on about them. Since the sense of fatigue is dimin-
motor
activity.
ished, they
do not
feel
feel
the need for rest, so they busy themand are up again early in the morn-
selves until late at night
about on all sorts of business. They take long

devote
much time to pleasure, begin a diary, write
walks,
many letters, undertake long journeys to renew old acquaint-
ing, bustling
and do many other things which they never would

have thought of before. They suddenly change their occuances,
pation, attempt journalism, write verse, purchase property,

give away many presents, build castles in the air, and start
numerous undertakings that are beyond both their

capital and physical strength. Their actual capacity for
work, however, is much diminished. They lack perseverance, become negligent, and apply themselves only to that
which is agreeable.
In general demeanor it is obvious that the patients are
self-conscious and attempt to attract attention.
They
in
393
dress in a conspicuous manner, and adorn themselves with

and cosmetics. Their handwriting is characteristically large and coarse, with a display of many exclamation
flowers
and interrogation marks and much underlining.
In the
presence of others they always press forward, seek to assert

themselves, talk a great deal, gesticulate, and boast. They
are apt to be discourteous and offensive in manner. In
spite of deep
mourning they indulge
in boisterous pleasures.
In the presence of women they relate questionable tales.

They make free with strangers and persons of high rank,
as if they were old friends. Their tendency to indulge in
all sorts of
is particularly prominent.
They
and smoke, remain out late at night,
keep questionable company, frequent saloons, and eat ex-
extravagances
often begin to drink
Women
cessively of rich foods.
are particularly apt to

show increased sexual desires, and to dress in a striking
manner, to attend dances, to read trashy novels, and to
fall
in love.
Not
infrequently, betrothals and pregnancies

Patients show extraordinary
result during such attacks.
craftiness
in
this
peculiar
attempts on the part of
often irritate the patient,

bursts
The
and
senseless
relatives to control
and
behavior.
All
them
are vain,
give rise to passionate out-
and even
aggressiveness.
disease picture as seen in the individual cases varies
considerably. The milder the disease process, the greater

the opportunity for the individual's characteristics to enter
into the
Personal peculiarities are particularly apt to show themselves in the emotional field.
symptom
picture.
While many patients remain amiable, tractable, and approachable, and are troublesome only because of their restlessness,
others are extremely disagreeable on account of
their imperiousness,
activity.
irritability,
and
reckless pressure of
394
The number of hours of sleep is cut

Physical Symptoms.
short by late retiring and early rising, but the actual sleep
The appetite is regularly improved, and the
The skin appears healthy, and the
weight may
movements are strong and elastic.
The course in this form is usually uniform. Improvement is very gradual, and often accompanied by remissions.
The duration is seldom less than several months, and sometimes lasts over a year. The disease may, however, last
is
profound.
increase.
for only a
few days.
This condition often follows mania.
Mania (Tobsucht).
The border line between hypomania and the less severe forms of manic excitement is not
always sharply defined. The onset of mania is almost
always sudden, following a short period of headache or
malaise, although a few days of simple depression may precede the onset. The patients rapidly develop great psycho-
a pronounced flight of ideas, clouding of consciousness, disorientation, and great impulsiveness.

Consciousness is more or less clouded. This is seen in
motor
restlessness, with
partial or complete disorientation.
Patients
know
the time
and where they
are, but they perceive only in a superficial

way the events of the environment. They mistake those
about them for old acquaintances. Sometimes they desig-
nate them as historical personages, as congressmen, public

officials,
or
well-known
greatly interfered with
millionnaires.
Apprehension
by the extraordinary
is
distractibility
sounds from the surroundings are caught up and woven

into their speech; an object held by the physician, or parts
of his clothing, attract the attention and quickly lead the
thought in another direction, which
is
just as abruptly left
before the thought is half expressed, aiding in the production of a flight of ideas.
Patients understand what is said
to them,
and are able
to give short, correct,
and pertinent
answers to questions.
395
In this way facts concerning their
and occupation can be obtained by piecemeal.

past
Very often a patient shows some insight into his disordered
condition, admitting that he is crazy and cannot control
lives
himself.
In emotional attitude the patients are mostly happy and

exuberant. Irritability, on the other hand, is very marked.
Trifling affairs, such as interference or contradictions,
may
lead to outbursts of passion with profane abuse, assaults,

or destruction of the clothing or other objects. The rapid
changes of the emotions are still more characteristic. In

the midst of joy they begin to lament and weep at the thought
of home, or because of abuse by their nurse. Abrupt changes
to a condition of passion and rage are not infrequent.
In the psychomotor field there is great activity and excitement. Patients cannot sit or lie still; they run back and
forth, dance about, turn handsprings, sing, shout, and prat-
make all sorts of gestures, tear off clothing,

down
the
hair, clap the hands, smear the person and
pull
room with grotesque designs, and ornament themselves
in the most fantastic manner with clothing which has been
tle incessantly,
strips, as shown in Plate 11. Everything that they

can lay their hands upon, from watch to shoes, is taken to
torn into
Bits of straw and pieces of stone, glass, and food

are hoarded to plaster up a crevice in the wall or to pack a
keyhole. In the absence of tobacco all sorts of material
pieces.
are used,
leaves and bits of bread and even dried feces.
They are especially apt to cram the nostrils and ears with
foreign material, and to carry bits of glass, nails, stones, and
nutshells in
the mouth.
four-inch nail and
One
of
my
patients secreted a
an extracted tooth in his mouth for months.

are
They
quarrelsome and domineering, or mischievous
and playful. Because of great irritability, the most trivial
396
affairs
may
patients are
lead to extreme violence
more apt
to
show
this
and abuse.
Female
tendency than male.
manifest in shameless masturbations,

exposure, and demands for intercourse, by indecent attitudes and insinuating remarks.
Sexual excitement
Some
is
of these cases of
mania may show
shorter period complete dazedness.
a longer or
The patients then apfor
prehend their environment only in a fragmentary manner

and are wholly disorientated. There is also great incoherence
of speech, often combined with pronounced hallucinations
and delusions. The hallucinations are usually transitory.

Sometimes faces are seen on the wall, shining objects appear
on the ceiling, and flash-lights are seen as signals in the sky.
Noises are heard, floors creak, locomotives whistle, bells
ring, and poisonous vapors are set free in their rooms at
Sometimes they complain of feeling electric shocks.

Delusions are mostly expansive, seldom depressive. They
are changeable and embellished by numerous fabrications.
night.
Patients claim that they are royal personages or generals,

that they have supernatural strength, can produce planets,
and are related to God, etc. Many of these ideas are recognized by the patients as pure fabrications, are expressed
with a laugh, and forgotten the next moment.
The sleep is usually much disturbed,
Physical Symptoms.
and the patients may go weeks with almost no sleep. Nutrition suffers in spite of increased appetite,
but food
is
taken hurriedly and irregularly. There often occur attacks

of syncope, and sometimes even convulsive attacks of a
hysteroid character. The heart's activity is usually increased
and the pulse slowed, while the blood pressure is diminished. The urine is found to show a striking diminution of
the phosphates, while calcium and magnesium are increased.

of urine also is often increased.
Pilcz has
The quantity
PLATE
11.
Self-decorated manic patient.
397
shown that both in the manic and depressive phases there

is excreted an abnormal amount of acetone, diacetic acid,
indocan, and albumoses, which, however, bear no definite
relation to the intensity of the
symptoms.
The height of the disease is usually reached in

the course of a week or two, and in some cases within a
few days. The intensity of the symptoms is fairly uniform,
Course.
with
only
slight
fluctuations.
there
Occasionally
may
appear a sorrowful and depressed emotional condition,

with disappearance of the motor activity, or even a tran-
Genusome time
sient stupor, indicating a transitory depressive state.
ine
improvement
is
very gradual; furthermore, for
after the return of comparative clearness, the patients are

apt, under strain, to show a flight of ideas and some in-
Even after apparent complete recovery,

reverses
and misfortunes, and more often
trying conditions,
intoxication can cause a recurrence of the symptoms. The
creased activity.
duration varies considerably, from a few weeks and even days

to many months, and sometimes two or three years. The
usual duration
several years.
many months. Some cases extend over

The cases with many delusions and those
is
with exacerbations of excitement

Delirious Mania.
is
characterized
last longer.
This, the extreme of the
by pronounced dreamy
manic
states,
clouding of conscious-
ness , intense psychomotor activity, great incoherence of speech,
a marked
flight of ideas,
numerous hallucinations, and dream-
like delusions.
These cases are very rare, and there
is a question if they
to
really belong
manic-depressive insanity. The onset is
sudden, following a few days of indisposition, uneasiness,
and insomnia. The patients suddenly develop the greatest
possible restlessness with
many
present in all of the sensory fields
hallucinations,
:
which are
they see beautiful sights,
398
strange faces, and scenes of torture; hear distant music,

ringing bells, cannonading, and the roar of wild animals.
Their food has a peculiar odor and taste, and small objects
crawl on the skin. They see fire and hear the crackling
Everything is changed. At the same time maniconfused, and dreamlike delusions appear, both of an
timbers.
fold,
"
chosen
they are the
have
been
elected
have
wonderful
ones,"
Presidents,
power,
can create and destroy nations, possess millions ; they have
expansive and of a depressive nature
lost all friends, are to
be murdered, must enter
been taken to an immense height, and are
now
hell,
have
to be cast
into the sea, etc.
From
the
first
disorientation
is
the consciousness
almost complete.
greatly clouded, and

The patients are thorand persons; they misis
oughly confused as to time, place,

take their environment, and even their friends.
Their speech is incoherent, abounding in sound associa-
rhymes, and numerous repetitions of single syllables

and phrases, in which one can always detect many fragtions,
mentary references to objects in

tention usually
their environment.
At-
cannot be attracted except momentarily,

of the desired response can be detected
when a fragment
Striking objects, such as a penny

on
the
will
divert
the attention and the train
dropped
floor,
of thought for a moment.
in the incoherent speech.
As
to the emotional attitude, the patients
show various
changes between extreme happiness and profound distress,

and timidity, exuberance and apathy. Irri-
ecstatic joy
marked.
In the psychomotor field the patients exhibit, from the
beginning, signs of the most extreme excitement. They
run about shouting and singing, disrobing, destroying everytability is very
thing within reach, and
they become
recklessly violent
and
smear
399
themselves.
Occasionally they impulsively

attempt suicide. At one moment they are praying, at the
next cursing with the vilest language, or singing an obscene
song; at one time they are insulting in speech and action,

later are profuse in apologies and distasteThey chatter away, scream and stamp
fully affectionate.
and a minute
pound the window or door, race about at the

greatest speed, mount the furniture and declaim in a loud
voice with profuse and exaggerated gestures.
The state of nutrition suffers
Physical Symptoms.
profoundly because of the small amount of food taken and
their
feet,
the excessive expenditure of energy. Occasionally there is

a general muscular tremor. Sleep is greatly disturbed, and
at the height of the disease is entirely lacking; the pulse
accelerated and the reflexes are exaggerated. Sometimes
the conjunctivae are injected, and the vessels of the head
and face distended. Occasionally there is profuse peris
spiration.
The height of the attack is quickly reached,

within
a few days or weeks, and the symptoms
usually
begin to abate at the third or fourth week. Brief intervals
Course.
composure often occur for a few minutes or a few hours,

during which the consciousness remains clouded. The
of
improvement may be rapid, i.e. over night, but usually is

gradual. For some time the patients, although clear, usually
retain residuals of their hallucinations, delusions, and peculiarities of conduct, and are especially inclined to be
irritable
and
distrustful.
But even these
disappear in the course of a
few weeks.
signs
There
entirely
is
rarely
any memory for the events of the acute stage of the psychosis.
The disease may terminate fatally as the result of
exhaustion, injuries, fat embolism of the lungs, or intercurrent infections.
400
happens that following a manic attack the

a low-spirited condition with more or less
exhibit
patients
general weakness, which sometimes is regarded as a sort of
It very often
reaction, but
which
really represents a
transition into a
These patients tire very

to apply themselves to either physical
characteristic depressed phase.

easily,
and are unable
or mental work, are despondent, worry about the future,

are reticent, sluggish, and indecisive. These symptoms
gradually disappear with the increase of weight. In some

instances, where the condition is more severe, there may
remain a permanent lack of judgment and

emotional irritability, and also restlessness.
insight,
some
DEPRESSIVE STATES
The depressive states comprise simple retardation and

the delusional form.
The mildest form of the depressive states is characterized by the presence of simple retardation unaccompanied by
any hallucinations or
delusions,
and
is,
therefore,
termed
simple retardation.
The onset
is
generally gradual, except in a few cases

illness or mental shock.
There appears
which follow acute
gradually a sort of mental sluggishness: mental processes
become retarded, thought is difficult, and patients find difficulty in coming to a decision, in forming sentences, and in
It is hard
finding words with which to express themselves.
in
or
for them to follow the thought
ordinary conreading
versation. The process of association of ideas is remarkably
retarded; the patients do not talk, because they have nothing
to say; there is a dearth of ideas and a poverty of thought.
Familiar facts are no longer at their command, and

to remember the most commonplace things.
it is
hard
In spite of this great slowness of apprehension and thought,
401
consciousness and orientation are well retained.
Patients
appear
sluggish, and explain that they really feel
tired and exhausted.
They sit about as if benumbed, with
folded hands and bowed head, exhibiting no initiative and
What is said is uttered
rarely uttering a word voluntarily.
dull
in
low,
and
inexpressive tones.
Customary
actions,
such as
walking, dressing, and eating, are performed very slowly,

When started for a walk, they
as if under constraint.
halt at the
doorway or at the
which way to go.
first
turning-point, undecided
Their usual duties loom before them as
huge tasks, because they lack strength to overcome the retardation, and anything new appears unsurmountable.
Sometimes they become bedridden. Because of this extreme retardation, the patients rarely commit suicide, although they often express the desire to
die.
Attempts at
more to be feared when the retardation has

and
while the despondency still persists.
appeared,
suicide are
In the emotional attitude there
The
patient sees only the
is
dis-
a uniform depression.
The past and

unhappiness and misfortune.
dark side of
life.
the future are alike, full of

Life has lost its charm; they are unsuited to their environ-
ment, are a failure in their profession, have lost religious

faith, and live from day to day in gloomy submission to
their fate.
Everything
pleasure in
life
is
spoiled for them;
and do not care to
they take no
live longer.
ill-humored, gloomy, shy, sometimes
pettish or
They are
anxious,
and sometimes irritable and sullen.

They fear business
reverses and begin to economize, even denying themselves
and their families the necessaries of life.
Sometimes numerous compulsive ideas appear. Patients
compelled, against their will, to ponder over certain
things, and to busy themselves with depicting unpleasant
scenes.
Others worry themselves over the thoughts of how
feel
SB
402
they might be martyred or torn limb from limb. Even

compulsions to act arise, such as to commit injury or to
set fire.
frequently present, the patients appreciating

that a change has come over them. This very often is
is
Insight
characteristically expressed as a feeling of inadequacy.
"
patients say:
my
own."
"
am
not
sick, I
am
"
I can't pull myself together."
energy, I can't get hold of myself."
The
only lacking a will of

"
have no
gone and
Sometimes the
I feel all
I can't make up my mind to do anything."

recurring sadness is ascribed to external influences, such
as,
unpleasant experiences, changes in the environment, etc.

The condition of retardation may, at some time during
the course of the psychosis, become so pronounced as to
produce a condition of stupor. Patients then lie abed perfectly dumb, unable to comprehend their surroundings, or
to understand even simple questions.
There
is
no particular
emotional change to be noted, except occasionally when a

look of anxiety or perplexity flits across the countenance.
Voluntarily, the patients almost never speak. If able to
answer questions, their responses are exceedingly slow-
They
sit
helplessly before their meals, allowing themselves
to be fed
firmly whatever may be

These patients are unable to
by spoon, and holding
pressed into their hands.

care for themselves, but are not filthy. This condition of
stupor tends to disappear rapidly, and leaves no memory
of the events of the period.
Simple retardation runs a rather uniform course, with few

The improvement is gradual, and the dura-
variations.
tion varies from a few
months
to over a year.
second group of depressive cases has been termed the
delusional form, which is characterized

varied depreciatory delusions, especially
by
of
the presence of
self-accusation
and
of
a hypochondriacal nature, in addition
to the
403
evidences
of retardation.
The
onset of this
form
is
usually subacute, following a
and occasionally even a short period

of exhilaration and buoyancy of spirits; a few cases appear
after an acute illness or mental shock.
The patients become profoundly despondent, and indulge
period of indisposition,
They feel that they have been

great sinners, have neglected their duties and made many
enemies, have never done anything right, and their whole
life has been one long series of mistakes.
They accuse
in all sorts of self-accusations.
themselves of bringing misfortune on others or of causing

some great calamity. They claim that they are devoid of
They feel that they are
feeling and sympathy for others.
arrest
and
fear
being watched,
imprisonment, they must
die, are to be poisoned or shot. Others hold them in derision,
laugh, and jeer at them. Their families are incriminated
by their misdeeds, and are suffering imprisonment. They
have lost everything, and will be driven into the street with
their families, to wander about in utter misery.
Hypochondriacal delusions are prominent and are usually
associated with numerous false bodily sensations: their
health
is
ruined as the result of masturbation;
they are
succumbing to some malignant disease, and their organs are

wasting away; cloudy urine signifies profound disease of
the kidneys; they can never recover, and their body and
face are altered.
Female patients complain of being pregand
often accuse themselves of immorality and masnant,
turbation.
These various delusions often become absurd and fan-
A common
is that everything about them

not their own; their friends and
relatives have disappeared forever; they do not belong to
tastic.
is
altered:
their
delusion
home
is
404
this world; they themselves are changed, are
but a skeleton
and cannot die. Though

life, they cannot live
struck on the head or pierced in the heart, they would still
live on.
Their heart has ceased to beat ; their stomach and
without
intestines are entirely gone; there are
throat with
to the
dried
up
no
feces
they are
decomposing food; their skin
full
is
all
their bones are softening, etc.
Hallucinations
are
occasionally
associated
with
this
when groans and moans
are heard, disagreeable

condition,
odors permeate the room, terrible apparitions appear at
night, and fearful scenes are depicted.
The
consciousness
is
for the
most part unclouded, and the

and comprehend correctly
patients are usually oriented,
what
transpires in their environment, although occasionally

they develop some delusional ideas in reference to the home
or institution and the persons around them. They under-
stand questions and answer coherently, but the content of

thought and speech shows a constant tendency to revert
to their depressive delusions. Thought is retarded, as shown
in their attempts to write letters or to solve a problem.
Insight into the condition
very often present, yet while
is
admitting recovery from previous similar attacks, they declare that their present condition is so much worse that they
can never recover. Some of these patients go to an institution of their
own
accord.
The
emotional attitude
is
uni-
formly one of depression. The patients are dej ected, gloomy,

and perplexed, and lament for hours in monotonous tones.
They say little to those about them, but sit staring into space
and paying very little attention to their environment. It,
however, becomes evident during the visits of friends and
relatives that they are not only not apathetic,
but capable of
showing considerable feeling.

Psychomotor retardation of thought and action
is
evident
405
and slow and hesitating replies to questions, their sluggish and languid movements, their lack of independent activity and inability to
in their dearth of ideas, their silence,
apply themselves to mental work. Some patients at times

exhibit anxious restlessness, pacing up and down the room,
swaying the body or rocking uneasily in a chair, picking at
the clothing or rubbing some part of the body.
attempts are not infrequent.
Stuporous
states
may
Suicidal
also develop in this delusional type
The
patients then develop a condition

of befogged consciousness, in which almost no external
impressions are apprehended and consciousness is domiof depressive cases.
nated by numerous variegated and incoherent delusions

and hallucinations. Everything appears changed in the
most fantastic manner; the whole world is being consumed
by fire or congealed into ice. They themselves are removed
from everybody, have been taken up into a cloud and
carried off to the farthest point of the universe, and left
to be shoved off into space, where they
will keep falling forever, or they are crowded into a narrow
there alone.
They are
grave from which they can never escape. The walls of the
room are closing in upon them, and passing troops have
arrived to attend their execution. Crowds jeer at them;
they are made to wear a crown of thorns, or are turned loose

to run naked in the street. Everything about them has a
most mysterious aspect; they are in the midst of historical

personages, and are made to do penance for the whole world.
They have been transformed in a most horrible manner,
are of a different sex, are swollen to the size of a cask, have
two heads, the body of a serpent, and the feet of an elephant.
While in this dreamy state their retardation is shown by
their inability to speak, to feed themselves, or to care for
themselves in any way. They do not show active feelings,
406
but
An
stupidly in bed, are inaccessible and indifferent.

occasional anxious expression, the resistance to passive
lie
movements, peculiar postures, and unexpected, impulsive

attempts at suicide betray their anxiety and fear. Sometimes a few words or sentences are uttered very slowly
and in low tones. These stuporous states disappear gradually, but even after consciousness has become clear, a few
hallucinations
and
delusions
usually
persist
for
some
time.
There are a few cases which present coherent delusions

accompanied by many hallucinations with
The hallucinations play a rather imclear consciousness.
of persecution
portant part and persist for a long time, reminding one

very much of acute alcoholic hallucinosis, save for the
psychomotor retardation.
The patients complain of numbPhysical Symptoms.
ness in the head, ringing in the ears, dizziness, palpitation,
chilliness in the neck, heaviness in the limbs, and of a feeling
as if there was a weight upon the chest. The appetite is
poor, the tongue coated, and the bowels constipated. There
usually a strong aversion to food, and it often requires
considerable urging to administer sufficient nourishment.
is
The
The
and
much broken and
disturbed by anxious dreams.

facial expression and the general attitude are sleepy
languid, the speech low, the eyes lustreless, the skin
sleep
is
The body
and
cardiac
Respiration
activity
weight always
are weakened and slower, and blood pressure is increased,
while the pulse is slow. The quantity of urine is diminished as well as the excretion of urea, phosphoric acid, and
magnesia. The height of the disturbance is reached in a
few weeks and runs a shorter course than the manic
sallow and without its accustomed firmness.
sinks.
states.
407
MIXED STATES 1
In
these
states
occur
there
simultaneously varying
combinations of some of the fundamental symptoms character-
manic and depressive phases of the disease.

The mixed states are most clearly seen during the transition periods when patients pass from a manic to a depressive
phase or vice versa. At these times all the symptoms of one
phase do not disappear simultaneously, so that symptoms
istic of both the
of the depressive phase develop before all of the
manic
symptoms
For instance, the characteristic

ideas may have given way to typical retarda-
manic disappear.
of the
flight of
tion of thought, while there
and pressure
of activity.
still
remains emotional elation
few days farther along in
this
transition period, we find that there still is some elation,

but retardation of activity has also developed. Later still,
elation has given way to depression, and we have the
In another case
typical picture of the depressive phase.
and the
during this transition period, the emotional elation may be

the first symptom to subside and pass into despondency,
while there still remain pressure of activity and flight of
ideas.
In a few days the
flight of ideas also
into retardation of thought, while there
is still
has gone over
some pressure
Farther along, we find the pressure of activity

replaced by retardation and the typical depressive picture.
All together there have thus far been recognized six chief
of activity.
types of mixed states.
mania, in which a depressed emotional state

the
usual
elation. These are the cases of pronounced
replaces
manic excitement in which the patients exhibit a more or
(1)
less
1
Irascible
constant irritability; they heap abuse upon the environWeygandt, Ueber die Mischzustaende des manisch-depressiven
seins.
Habilitationsschrift, 1899.
Irre-
408
ment, and become passionately angry and even aggressive

upon the slightest provocation. If the excitement is not
quite so pronounced, there is produced the picture of the
grumbling mania, in which the patients show a feeling of
somewhat increased
self-confidence,
but without
elation.
are dissatisfied, intolerant, perhaps a little anxious,

have some fault to find with everything, always feel that they
are mistreated, are served poor food, and have to sleep on
They
a wretched bed.
They have a
facility for offending
and
vexing others, and for instigating trouble for every one about
them. Each day they have a new complaint, and become
The fundamental manic
irritable if they are not heeded.
symptoms
instability,
are seen in the moderate flight of ideas, the great
and
restlessness.
Depressive excitement comprises those depressive

cases in which the restlessness is out of all proportion to
the intensity of their emotional despondency. These pa(2)
but always about the same thing they

torment themselves and their environment by the same old
tients talk incessantly,
complaints ; they are forever expressing the same delusional

ideas, mostly of a hypochondriacal nature and usually in
the same phraseology.
They complain that they have been

have
been
poisoned, can never recover, and are
mistreated,
going to die, but at the same time they are not especially
anxious or sad, and they are able to apply themselves without fatigue. They may even, for short periods, make humor-
ous or sarcastic remarks, and show some
irritability
and
aggressiveness.
Unproductive mania is the manic state with dearth

This form is often encountered. The patients are
very slow and inaccurate in perceiving. One often has to repeat a question several times before they understand it. They
(3)
of ideas.
don't pay attention, give
many
false
and evasive answers.
409
give one the impression that they are weak-minded,

but later they prove themselves to be quite intellectual.
This condition of unproductive mania fluctuates considera-
They
bly; at one time the patients
answers, while at another
may
it is
temporarily give ready
impossible to get anything
out of them.
The emotional
one of elation, happiness, and

exuberance; they laugh readily and without sufficient cause
and make fun over every little thing. Their speech is inattitude
is
coherent and the content limited.
They speak slowly and
do not have much to say; indeed, if left to themselves, they

remain speechless for long periods. It is characteristic
of the thinking difficulty to be more intense at the beginning
of an interview, but as the conversation is prolonged, the
patients gradually develop considerable pressue of speech.
There
is
always present an increased emotional
irritability.
The
pressure of activity is usually confined to grimacing,

occasional dancing around, changing the clothing, and fussing
with the hair, but the patients never show the restless busy-
ness so characteristic of mania.
Many
of these patients
ordinarily conduct themselves so well and quietly that a

superficial examination fails to reveal any excitement.
Nevertheless, they are in an elated frame of mind, at times

showing irritability; they are tractable or rude, and often
break out in boisterous laughter. Other patients are inactive and sit around, but upon the slightest provocation
or, for no apparent reason, become
are
saucy.
They
incapable of any orderly employment, but
are rather given to all sorts of mischievous tricks, stealing
they laugh uproariously,
and hoarding a lot of things, tearing up papers and clothing

and tying knots in them, plugging up keyholes, and pasting
paper designs all over the walls. Sometimes they suddenly burst out in great anger.
Also, they may show
410
transient periods of genuine mania with flight of ideas

pronounced pressure of activity.
(4)
Manic stupor
is
and
the depressive state in which emo-
tional elation takes the place of the usual despondency.
The
patients are quite unapproachable; they do not bother

themselves about their environment, will not answer questions, laugh without apparent cause, lie quietly in bed,
sometimes
all rolled
up
in the clothing, or dress
them up
in
a fantastic manner, but all of this is done without evidence

of restlessness or emotional agitation.
Sometimes a few
changeable
delusions
well oriented.
are
Occasionally catalepsy
are
usually
present.
In the
They
expressed.
is
midst of this stupor the patients suddenly develop great

activity, rush about, disrobe, tear their clothing, destroy
smear their food, sing and talk loudly and freely,

often making bright and striking remarks, and then after
a few hours as quickly return to the previous state. At
other times one finds them quiet, perfectly clear and intellifurniture,
gent in conversation, but this
only for short periods.

Many patients pace about in measured steps, never speak
except to make an occasional witty remark, or rub up against
the doctor in an erotic manner, and laugh. These patients
is
often have a good memory for what occurs, but they are
wholly unable to explain their peculiar conduct. In some
cases the facial expression
is
fixed
and
staring, in others it
more cheerful, happy, and amorous.

Manic stupor often develops for a short time in a pronounced manic state, but it more frequently represents a
transition state between a depressive stupor and a manic
is
state.
Depression with a Flight of Ideas.

are
cases
easily aroused when they can
(5)
thought.
They read a good
deal,
show
These depressive
show a
interest in
facility of
and com-
411
prehend their environment, and, indeed, even evince some

curiosity, in spite of the fact that they are retarded in their
general attitude, are almost mute, and are despondent.
These patients tell us as soon as they begin to talk again
that they could not control their thoughts, that a whole
host of things would come into their minds which they had
never thought of before. It seems, therefore, that there
really exists a flight of ideas which, however, is not apparent
to others because of the retardation of the
articulation.
Some
movements
of these patients cannot express
of
them-
but can write, and often astonish one with

numerous productions, containing delusional ideas of
persecution and fear.
selves orally,
their
the depressive state with flight of

ideas and emotional elation. These patients are happy,
(6)
Finally there
is
sometimes somewhat
are distractible, prone to

witty remarks, and are easily aroused during conversation
to a flight of ideas and at times even sound associations,
irritable,
but in general their demeanor is quiet. They lie quietly

in bed, and now and then interpolate a remark or laugh
loudly.
Nevertheless there seems to exist an inner tension,
because the patients can suddenly become very violent.

The mixed states occur most frequently in the transition
periods from manic to depressive states and vice versa.
Indeed, it is only by the history of their development and their
transition into the well-known phases of the disease that
we are able to recognize them as mixed phases and as a
type of manic-depressive insanity.
This observation
is
of
which mixed states

almost wholly replace the typical manic and depressive
phases. In such cases the recognition of the disease,
especial importance in those cases in
particularly in
not impossible.
the
first
attack,
is
extremely
difficult, if
412
Course.
The course
of
manic-depressive insanity is
marked by a recurrence of attacks separated by lucid intervals. With but very few exceptions, attacks recur throughout
the
of the individual, appearing with greater frequency
life
between the ages of eighteen to thirty and forty to fifty.

In five per cent, of cases the attacks from the first pass directly from one phase into another, sometimes with such
"
"
has been
alternating insanity
apregularity that the name
of
if
have
intervals
or
short
to
lucidity
intervened,
them,
plied
"
If only one or two attacks occur during
circular insanity."
the
way
of
life
an
individual, the separate attacks are in
essentially different
no
from those recurring frequently.
seldom happens that all are of the same type; at some time
or other a depressive attack is sure to appear. On the other
hand, one patient during life may suffer from all possible
It
forms, from hypomania to profound stupor.

The first attack in sixty per cent, of the cases
is
depressive.
This is especially true in women, and when the disease develops early in life. The first depressive attack usually
runs a mild course, and in about fifty per cent, of the cases
followed immediately by a lucid interval. In the other
fifty per cent, of the cases it is immediately followed by a
manic attack, which in turn is followed by a lucid interval.
is
almost always followed by a lucid

If the first attack is
interval, seldom by a depressive attack.
are manic.
attacks
of
the
succeeding
manic, the majority
first
manic attack
is
several depressive attacks may recur before a

attack
manic
appears; in other words, the occurrence of
several attacks of one type to the exclusion of other types
Similarly,
indicates that the greater number of attacks throughout

Later in the course of
life will be of the same character.
be a regular alternation between

manic and depressive attacks. After a long duration of
the disease there
may
the disease there
more apt
is
413
to be a regular alternation
from one type to the other, if the early attacks have

been mostly of one type. The mixed forms usually do
not appear until after two or more manic or depressive
attacks.
The duration of the individual attack may vary from a

few days to five years, but the usual duration is from six
to twelve months. The depressive attacks average longer.
The first attacks rarely last longer than a few months. In
the circular type of the disease
alternates
it
has been observed that
with
simple retardation,
hypomania usually
while severe manic states are followed by deep stupor, and
again, when delusions and hallucinations occur in the manic
states,
they are usually also present in the depressive
states.
The
vary considerably in length, from a

few days or weeks to many years, and stand in no definite
lucid intervals
relation to the duration of the attacks.
are apt,
shorter as the
They
however, to be longer at the beginning and

attacks recur, until finally they may disappear altogether,
the attacks then passing directly from one into another.
At the beginning
of the disease the intervals are usually
of at least one or
more
years' duration.
Sometimes the
intervals are of such a definite duration that the patients
The intervals tend

just when to expect the attacks.
become shorter during the climacterium and to lengthen
out again later. Sometimes, especially in young females,
know
to
the disease begins with a series of several short attacks with

brief intervals, which are then followed by a prolonged in-
In the small group of cases in which

from the beginning the attacks succeed each other without
terval of several years.
lucid intervals, the type of the attack
hypomania and simple retardation.
is
usually light, mostly

Sometimes, even after
414
a long series of such recurring attacks, there
may appear a
long lucid interval.

During the intervals the patients are perfectly lucid,
except in a few cases where the attacks are long, frequent,
and
are able to reenter the family, to employ

themselves profitably, and to return to their profession.
severe.
They
The few who do not thoroughly recover are also usually

able to return home, but are apt to show some restraint,
lack of independence, a tendency to be morose, an unusual
susceptibility to fatigue, some sleepiness, and a diminished
capacity for work, or they may be irritable, quarrelsome,

markedly egotistical, or unstable and easily excitable.
During the interval some of the patients

thorough appreciation of their disease.
fail
They
to
show a
will
admit
"
excited and nervous/' but attribute

that they have been
it to some family trouble or confinement.
It
very often happens that during the intervals the pamay suddenly develop short periods of moderate
tients
exhilaration, flightiness, irritability,
and unusual
activity,
or on the other hand, they may be unnaturally apprehensive,
and indifferent. These

and
without the history of
symptoms disappear abruptly,
other attacks might not be recognized as disease sympsuspicious,
despondent,
inactive,
toms.
The
from a manic to a depressive phase, and

usually gradual, though it may be sudden,
transition
vice versa, is
often occurring during the night. In this transition the

stages of alteration are usually quite perceptible. At first
the countenance of the depressed patient becomes more
illuminated and the eyes appear brighter and the skin firmer
and more
elastic.
The
dom.
His activity, at
is more affable, shows more

and expresses a desire for freeincreasing slowly, now becomes
patient
interest in the surroundings,

first
prominent;
he
is
busy
all
the time,
is
415
happy, never
felt
From this time

life, and everything pleases.
the manic state becomes quite evident. The manic patient
better in his
at
gradually loses weight, the pressure of activity abates,

calmer and more in earnest, his many schemes recede
first
he
is
to the background
and then
movements become
Soon
entirely disappear.
languid, he himself
is
his
seclusive, talks
and misonly occasionally mentioning

its
and
His
countenance
loses
at last
fortunes.
freshness,
we have a typical depressive state.
his ill-feelings
less,
There
usually little difficulty in recognizing the psychosis, where there has been a previous attack; yet the occurrence of more than one attack is by no
means pathognomic of manic-depressive insanity, as it
Diagnosis.
may happen
in
is
dementia prsecox, especially in the catatonic
form, in paresis, melancholia, and in amentia.

It is difficult to distinguish between the mildest forms
of manic-depressive
peculiarities
insanity
and
certain morbid personal
which manifest themselves
chiefly as a
more
The manicon the one hand, and of

impetuous exhilaration on the other, are sometimes mistaken as simple whims and ascribed to all sorts of deleterious
or less regular vacillation of the emotional state.

depressive periods of ill-humor
influences, or
they are apt to be designated as hysteria ,

since it is only in the
neurasthenia, and hypochondriasis,
depressive states that the patients are considered
ill.
These
same patients themselves, however, often have insight into

their periods of excitement and dread their approach.
Usually the true nature of the disease is disclosed
by the
transi-
tion from one phase to another, and by the periodic recurrence

of different phases. The simple lack of decision
the inability of the depressive patients to
characteristic that
it
come
to a conclusion
is
so
alone often suffices in making the diag-
416
These border-line cases are numerous, and are often

encountered in sanitaria.
In the mild forms of the manic states, when one sees the
nosis.
patient in the
patient's
first
life, it is
attack and
is without a history of the

often difficult to distinguish the patients
from some normal individuals.
The
distinction depends
upon the fact that the increased busyness and activnot uniform, but shows variations. In the forms of
chiefly
ity
is
constitutional
mania there are also noticeable aggravations

and regular transitions into opposite moods.
of the condition
Such
patients, because of their frequent conflicts with their
environment and the law, are usually considered swindlers

and vagabonds, or are regarded as morally insane. In addition to the vacillations, the clinical picture also shows
an attitude of overconfidence, an irritability, a lack of plan
in their excessive busyness, an excessive emotional irritability,
and a lack of criminal tendencies.

The differentiation of the disease from the exhaustion
psychoses and from the excited stages of the catatonic and
hebephrenic forms of dementia prsecox will be found fully
detailed in the differential diagnosis of those diseases.
The manic forms
are differentiated from hysterical excitethe presence of the flight of ideas, pressure of activity,
ment by
the exuberant emotional
hysterical
and the great distractiexcitement comes in the form of
brief separate attacks
with definite outbursts of temper.
bility.
The
state,
Hysterical excitement usually subsides quickly

pletely after a very short duration.
more
and com-
simple retardation from

the initial period of depression in dementia pmcox. In the
manic-depressive patients the psychomotor retardation,
with slowness of movement, low tone of voice, difficulty
It is
difficult to distinguish
of thought with sparsity of ideas, slowness of application
of attention,
and
417
slight clouding of consciousness, stands out
freedom of moveof consciousness

to
clearness
and
the
ments and thought,
in dementia prsecox. Rapid appearance of senseless delusions and numerous hallucinations without clouding of
in contrast to the absence of retardation,
consciousness speak for dementia praecox.

The differentiation of the depressive states from dementia
paralytica
and melancholia have been discussed under these
psychoses.
Acquired neurasthenia is sufficiently differentiated from

the depressed forms under that disease.
The unproductive mania is often mistaken for imbewith excitement, but can be distinguished by the evidences of flight of ideas and the manic demeanor of the
cility
patients with only moderate restlessness.

Manic stupor sometimes must be differentiated from
catatonia.
cause for
If,
it
in
lies
manic stupor, the patients

in
struggle, the
the irritable, fretful disposition which

Again, the
almost always leads to abuse and violence.
patients pay more attention to their environment, and are

influenced in their actions by circumstances, in contradistinction to the stupid or wilful indifference of the catatonic.
Furthermore, the manic-stuporous patient displays a poverty of thought and not a stereotyped and senseless speech
The movements of the catatonic are apt to

be planless, impulsive, and with a uniform pressure of move-
production.
ment, while in stuporous mania they are purposeful, playful, and adapted to the environment.
The prognosis of the disease is unfavorable

Prognosis.
view of the certainty of recurrence of the attacks throughout the life of the individual. It is favorable for recovery
in
from the individual attacks, except in five per cent, of cases,

which from the onset pass directly from one attack into anSa
418
While, with this exception, there are almost certain

be
to
other attacks and recoveries, the frequency of their
other.
recurrence and the duration of the lucid intervals

uncertain.
At present we have no means
is
wholly
of judging just
what the future course
will be.
In general it may be said,
that
it
is
to
safe
however,
predict frequent recurrence of
attacks with short intervals where the psychosis manifests
itself early and without external cause.
On the other hand,
if
the
first
attack occurs late and following some external
cause, such as childbirth, there probably will be but few

If pronounced mixed states predominate, the
attacks.
If the onset is predisease will probably be more severe.
vious to the period of involution, one should expect a recur-
rence during the climacterium.

Mental deterioration occurs in only a few cases, where
the attacks appear during the period of development and are
long,
frequent,
and
severe.
Even
these
patients in the
and retain a very

good memory. They simply show some indifference, irritability, an increased susceptibility to alcohol, and slight
intervals are
conscious, well oriented,
There are a few cases that have

manic
attacks, lasting even ten years and more,
very long
which have been designated chronic mania. This condition is not one of dementia, but one in which there are
deficiency in judgment.
incomplete remissions. If observed carefully, these cases

usually present not only manic states of varying intensity,
but also evidences of depressive and mixed states. Furthermore,
it is
usually found that even in the lucid intervals the
patients have always been somewhat unstable, freakish, irritable, or have been schemers and incapable of any consistent
and productive employment.

constitutional
There
is
These cases are better termed
mania.
a corresponding series of transitions from the
419
depressive states. There are manic cases which in the intervals are shy, low spirited, and slow to make up their minds.
This defective constitution
is
more
characteristic in those
who suffer from periodic depressive states.

there
are cases in which the separate attacks of
Finally
periodical ill-humor present themselves without sharp
individuals
and are simple aggravations of a constitutional depression.

Arteriosclerosis, or marked senile changes,
differentiation,
developing during the course of manic-depressive insanity,

usually lead to states of dementia which obliterate the original mental picture.
Treatment.
The
disease, being deeply rooted in the per-
sonality of the individual, offers little chance to eradicate
the underlying causes. Individuals who seem to be predisposed to the disease certainly derive benefit from leading
a careful life under favorable conditions and abstaining
absolutely from the use of alcohol.
Such persons should
not marry.
Individuals suffering from frequently and regularly recurring attacks can sometimes ward off an approaching
attack by the use of large doses of the bromides, even up to

three hundred and sixty grains a day for a few days before
the anticipated attack. Atropia, hypodermically, or bella-
donna
in the
form
of the extract in full doses, is highly recom-
mended for the same purpose. In those cases in which the

attacks tend to develop during pregnancy or puerperium,
artificial abortion has occasionally been performed for the
purpose of either warding off the attack or cutting it short.
Kraepelin himself has not derived much benefit from this
procedure, but finds that, in spite of abortion, the disease
recurs and runs its regular course.
In all such cases measures should be adopted for the prevention of pregnancy.
Individuals who have already suffered from an attack of
420
the disease should be compelled to lead a quiet
from
irritating influences.
The
life,
free
susceptibility to alcohol
is
increased, hence its use should be most scrupulously avoided.

In the treatment of the patient during the manic attacks,
the
first essential is
the removal of
all
forms of external
Except in the mild cases, it is unsatisfactory

to attempt to care for the patient at home, and even the
milder forms run a more moderate course under the influ-
excitation.
ence of a quiet and well-regulated hospital or sanitarium

environment than at home. Unrestrained activity tends to
increase the excitement
therefore the pressure of activity

should be limited as much as possible. One of the best
means
of accomplishing this
treatment
is
is
confinement in bed.
especially indicated in
Bed
anemic and debilitated
cases.
In severe excitement prolonged warm baths (see p. 140),

used in connection with the bed treatment, give the most
satisfactory results. The patients should alternate from
the bath to the bed
i.e.
when the excitement subsides
in the
bath, he can be returned to the bed until it reappears. It

may be necessary in order to first introduce the patient to
the bath to give a preliminary dose of hyoscin hydrobro-
mate (-^Q
to
-^ grain).
The prolonged warm bath properly

the greatest excitement, and usually
applied will often relieve

renders medicinal treatment unnecessary. If the bath is
not available, the use of hyoscin hydrobromate hypodermically, or
by mouth,
is
the best remedy for subduing the
intense psychomotor activity. Scopolamin hydrobromate

("2To to -&fi grain) or paraldehyde may be substituted for the
hyoscin.
As the excitement permanently
subsides,
con-
finement in bed can be gradually relaxed and the patient

given an opportunity to exercise in the open, fin very
extreme excitement with impending collapse the adminis-
421
is necessary, and
cardiac
weakness, digitalis or
coexisting
The
caffein should be added.)
general management of the
tration of whiskey of
brandy or camphor
in the case of
patient is usually a very important adjuvant in controlling

the excitement. This requires the greatest amount of tact
and patience on the part of the nurse; gentle friendliness

at suitable moments sometimes renders what appears to
be a most dangerous patient quite tractable. The nurse
must exercise self-control, be free from all prejudice, avoid
the use of discipline, and above all be frank and truthful.
The nutrition of the patients demands special attention.
An abundance of nutritious and easily digested food should
be given the patients at regular intervals. They should
not be allowed to gulp their food, and hence it usually requires the constant attendance of the nurse at meal-time.
Because of the great restlessness, it often requires consider-
able patience to get an excited patient to take sufficient

nourishment. In severe cases the patients should be weighed
frequently in order to ascertain if the body weight is falling
off, and, where necessary, artificial feeding by stomach or
nasal tube can be employed.
It is very often a difficult matter to determine just when

manic patients have recovered sufficiently to be discharged
from treatment. Because of their great importunity and
impatience to be set free, there is a tendency to discharge

them while some symptoms still remain. One of the dangers
premature release is the tendency to alcoholic indulgence,

which regularly leads to a recurrence of the symptoms.
The safest guide in deciding this question may be found
in the body weight, which should have returned to normal.
In the depressed states the patients should at once be
in
given the benefit of the rest treatment with confinement in
bed and ample feeding.
Except
in debilitated
and anemic
422
cases, the patient should be permitted to leave the bed for

a short period during the day to take exercise in the open.
If this is not feasible, massage should be administered.
treatment taken in the open on a shielded but

sunny porch should always be tried in preference to indoor
confinement. If there is great agitation, opium in increas-
The
rest
ing doses (see p. 362)
is
often given with benefit.
The insomnia should be
controlled,
if
possible,
by the
aid of the variou^ physical measures, such as, hot baths at

night, hot liquid nourishment
etc.
and
upon retiring, gentle massage,

Failing with these, one may employ on alternate days
for short periods trional 15 grains, veronal 7J grains,
or paraldehyde 1 to 2 drachms. During prolonged periods

of administration, these hypnotics should be varied.
The
nutrition also
demands
careful attention, for
which
purpose the patient should be frequently weighed. The

food should be carefully selected and easily digestible. Abstinence from food often requires artificial feeding by nasal
or stomach tube.
exists, usually
The
relief of constipation,
which often
improves the appetite.
The patient must be relieved from all forms of excitation,

and visits from relatives, long conversations, letter-writing,
Rational conversation and encouretc., should be avoided.
agement is helpful, except at the height of the disease, when
sometimes seems to be aggravating. In the lighter cases
hypnotic suggestion has been used to great advantage in
it
and disagreeable somatic sensations. The greatest care must be exercised to

prevent suicidal attempts, which are often to be most guarded
relieving the insomnia, despondency,
against at times when the patients, though still convalescing,

believe themselves recovered, and also in the transition
periods between attacks.
X.
PARANOIA
of
stable
marked mental
a chronic progressive psychosis
is
mostly in early adult
ment
PARANOIA
life,
occurring
characterized by the gradual develop-
progressive system of delusions,
deterioration,
without
clouding of consciousness, or
disorder of thought, will, or conduct.
The disease is uncommon, constituting only

Etiology.
one to four per cent, of the cases admitted to insane hosMen are more often afflicted than women. The
pitals.
between the ages of twenty-five and forty. It
on
a
defective constitutional basis, either condevelops
disease begins
genital or acquired, defective heredity existing in a very

large percentage of the cases.
Peculiar traits
and eccen-
be recognized early in
life, the patients being

or
show perverted sexual
seclusive.
Some
moody, dreamy,
instincts, or a marked aptitude for study or mental activity
tricities
may
in special, limited fields.
Some have been abnormally bright
others have always been flighty, entering into many projects

which they were unable to pursue successfully; many show
stigmata of degeneration. Exciting causes occasionally

form the starting-point of the psychosis, such as an acute
illness,
excessive
mental
stress,
shock, business reverses,
deprivation, and disappointment.

1
Allgem. Zeitschr. f Psy., XXII, 368 Griesinger, Archiv. f Psy.,

I, 148; Sander, ibid., 387; Westphal, Allgem. Zeitschr. f. Psy., XXXIV,
252; Mercklin, Studien ttber primure Verriickheit, 1879; Amadie e
Snell,
Tonnini, Archivio italiano per
le
malattie nervose, 1884,
Die Paranoia, 1891; Schule, Allgem. Zeitschr.

Cramer, ibid., LI, 2 Sandberg, ibid., LII, 619.
;
423
f.
Psy.,
1,
2; Werner,
L,
u.
2;
424
There
is
as yet no demonstrable, pathological, anatomical
basis peculiar to paranoia.
Symptomatology.
is
The development
of
the psychosis
very gradual, extending sometimes over years, and
is
usually so insidious that the disease is in existence long

before it is recognized. During this period it may have
been noticed that the patient had changed in disposition,
having become somewhat
irritable,
grumbling, suspicious,
and that he had made indefinite

physical complaints, especially of malaise and insomnia.
The first symptom to be noticed is that the daily mental
or manual labor becomes distasteful, and little affairs at
home or in the shop cause displeasure and arouse suspicion.
The wife seems less attentive, the children less loving,
shopmates less friendly, and the overseer more stern. The
and
easily discontented,
accidental absence of the morning greeting, or imaginary

slight on the part of a close friend, sets the patient to think-
ing that
it
cannot
all
be accidental.
He becomes
distrust-
constantly seeking other evidences of unfriendliness,

and careful watching soon satisfies him that he is neglected,
ful, is
both at home and at work.

accuses his friends of slights,
He
make complaints,
and members of his fraternity
begins to
He
leaves his employment, holds aloof from his

companions and friends, and often becomes rude and discourteous. Some patients are able to ignore for a time the
of plots.
apparent indifference of friends, but others become much

disturbed and suspect a malicious purpose. They are morbidly sensitive, considering that such trifles as harmless
jokes, smiles, or accidental nods of the head have special
reference to themselves.
Items in the paper indicate some
posters contain hints, some daily passer always

lights his cigar or coughs when near them; men similarly
dressed always meet them near the same corner, or are shad-
intrigue, bill
PARANOIA
Any doubts
owing their footsteps.
pose in all this are sooner or later

accidentally overheard.
425
as to an evident purdispelled
by remarks
In this way false interpretations
gradually assume greater prominence, and the resultant

persecutory delusions are constantly increased and aggravated. Those who conscientiously approach and question
friends or supposed intriguers are further alarmed and justified by the indifference displayed and the little satisfaction
obtained; some ignore them, others answer evasively.
Trivial matters which formerly passed unheeded are now
falsely and absurdly interpreted and enter into the struc-
A spot on the coat, a calloused

a
or
a headache are all regarded as
decayed tooth,
finger,
positive proof of treachery and an effort to get them out
ture of their delusions.
a slow process of poisoning. The appearance

of natural baldness is readily explained by the application
of the
way by
of electricity during sleep.
Sooner or
later, in connection with these delusions of

which
are firmly held and well moulded by a
persecution,
coherent train of reasoning, there may also appear expansive delusions.
These may be coincident with the persecu-
tory ideas at the onset of the disease, but more frequently

are the outcome of the delusions of persecution. The increasing attention which the patients attract and the perthem to cast about for the reason.
sistent persecution lead
While some find
this in property
others believe that
it
lies
which they
really possess,
in their personal charms, while
others conclude that they have been born for a special

mission, or are of noble descent.
thrifty Irish woman, who
still
had accumulated considerable property by dint
of hardest
labor, finds a sufficient cause for her persecution in
of her enemies to secure
attempts
her hard-earned accumulations.
factory employee already approaching the limits of the
426
climacteric finds the reasons for her persecution in her
attractive appearance, and the desire of eminent men to

seduce her. Where the expansive delusions are more directly
evolved from the delusions of persecution, the patient asks
himself why he is so molested and tormented, why so many,
not only individuals, but nations, seem directly interested

in him, and why he is constantly accompanied by a secret
Gradually it dawns upon him that he is a kidpatrol.
napped son
is
crowned head, that he

and lawful heir to the throne,
of a millionnaire or of a
of Napoleonic descent
while his extensive landed properties are unlawfully used

by the government. This explanation first appears in the
tendency to find evidences of persecution in
many
or
all
the events of their environment, and becomes prominent

when the patients discover its purpose. Then all these
supposed facts assume a place in the chain of evidence

which confirms their conclusions.
These delusions
may
only assume the form of an exag-
gerated feeling of self-importance. The patient considers

himself especially renowned in his profession,
a fine
lawyer, an excellent teacher,
an
interesting talker,
an
ideal
gentleman, a social favorite, or an individual worthy of

great political distinction. Finally, a change of personality
may
result,
and the patient announces himself as titled, or

The patients become aware
a direct descendant of Christ.
of this in various ways, one once receiving a salutation
from
the
President, another recognizing a striking similarity

between himself and the equestrian statue of a famous
Others are assured of their high station by the

deference paid them by every one people bow to them, their
general.
names are
in the paper, the orchestra begins to play as they

enter the theatre, the prima donna directs her song at
them, and the birds chirp when they are near.
The appear-
PARANOIA
427
ance of the sun from under a cloud, casting its rays upon
them, indicates that they are under the special guidance of
God.
All delusions, both persecutory and expansive, are held with
great persistency, and built out into a coherent system, which
is
an
essential characteristic of the disease.
In the systematization of the delusions another prominent feature is the frequent appearance of retrospective
falsification
of
memory.
While
characteristic of paranoia,
it
this
may
symptom
is
mostly
also be present in the
paranoid forms of dementia prsecox and in melancholia.

Here the patients, in reviewing their past life, find evidences
of persecution, or detect occurrences which at the time should
have indicated their superiority. The loss of a situation

many years ago, derisive remarks by fellow-workmen, or
an
injury,
now become
clear evidences of their persecution
patient recalled that when thirteen years

of age a priest took from her a book, claiming that it was
unfit for her to read. This incident she now regards as the be-
by
enemies.
One
ginning of years of persecution by the priesthood, who would

seduce her and then hold her up as an example before the
world. Another patient led his class in marching, and later
was chosen captain
of the boys' brigade:
these incidents
made him aware
overhearing his
of the fact that he

Another remembered
parents whisper in an adjacent room, be-
coming mute at
his entrance,
at that time should have
was
to have been a
who was
famous general.
and
later a disguised
really his mother, visiting at the house,
woman,
all of
which
pointed to a noble birth and his displacement by a younger

similar incidents scattered throughout life
are pointed out as striking evidences which aid in fortify-
brother.
Many
ing their system of delusions.

An erotic element often appears in the delusions, which
428
some
cases has been pronounced enough to lead to the

recognition of an erotic paranoia. Likewise, the religious
in
coloring
is
sometimes strong enough to establish a religious
paranoia.
In the erotic cases the patient usually believes himself the
object of admiration by some lady who is attracted to him
and
She makes him aware of
solicits his attention.
this
by daily appearing at her window as he passes, or by casting

Other evidence is gathered
sly glances as she drives by.
by anonymous love poems in daily papers.
fantastic methods of communicating his love
Numerous
to her are
devised, to which she responds by wearing certain articles

Their
of clothing, or arranging her hair differently.
publicly regarded as an open secret.

indirectly referred to everywhere, and friends
mutual admiration
He
hears
it
is
would have him infer, from casual remarks, that they are
well pleased. Sometimes this fanciful, romantic, and even
platonic love is maintained for years without action; at
others the patient makes an effort to approach his supposed
fiance* e.
for the
Her
rebuffs
may
accomplishment
at
of
be regarded as necessary
Later she may
her desires.
first
appear to him in the guise of one of his companions.

Hallucinations are always present at some time, but do
not play a very important part in the psychosis, and rarely
Hallucinapersist through the whole course of the disease.
tions of hearing are apt to be the
most prominent.
At
first
Later they hear their

names mentioned, or derisive laughter from a crowd; nicknames are called out, some one curses below the window,
very indefinite noises
annoy them.
and bits of conversation from adjoining rooms excite them.

The remarks are more often of a depreciatory nature. Hallucinations of sight are rare, but those of general sensibilthe hair is plucked at night, the
ity are quite frequent,
PARANOIA
skin irritated
bullets,
by poisonous powder, the
429
flesh pierced
or the countenance transformed
by
by the nightly
application of an iron mask.
There
is
never genuine insight into the disease.
patient, on the other hand, may complain
The
of all sorts of
physical ailments, such as nervousness, indigestion, pains

in the head and back, for which he seeks medical attendance, but he cannot be made to realize the fallacy of his
delusional ideas. The memory is well retained, and judg-
ment, except as biassed by the delusions, is unimpaired.

The emotional attitude of the patients stands in direct
relation to the character of the delusions.
They
are
irri-
tated by their persecutors, are shy and excitable, and at

first usually despondent; some, however, tolerate the persecution
fare.
and regard
All
it
as essential to their spiritual wel-
sooner or later become arrogant, proud, and
dogmatic.
In conduct the patients appear quite normal for a considerable time.
Some
of them, long before the real nature
becomes evident, attract attention by their

eccentricities, peculiarities in dress, oddities in manner,
excessive religious zeal, or an attitude of self-importance.
Later they become seclusive, move about in their employment from city to city, leave one shop to enter another,
of their disease
where they soon detect the presence of their former perseIn this way an
cutors, and are again compelled to leave.
iron
moulder travelled from San Francisco to Boston in
order to avoid the persecutions of his trade-union.

change
affords only temporary relief to the anxiety, as suspicious
circumstances are soon noticed which leave no doubt that
news about them has been passed on from their last situation until finally their existence becomes known the world
over. They become unstable in their behavior and mode of
430
unable to conduct a successful business, and fail

to support their families. In reaction to the delusions
living, are
they attempt to
call
public attention to their persecution
by writing newspaper articles and issuing pamphlets. Very

often they apply to the police for protection. Frequently
they assume the offensive, and take the matter of vengeance
own hands. Not infrequently the first striking
into their
is a murderous assault upon some

The paranoiac is for this reason the most dangerous
of all insane.
One patient assaulted the mayor of the city
for keeping him from his fiancee; another drew a pistol upon
a man with whom he was having an altercation over business
matters, in the belief that he was the secret agent of the
evidence of the disease

one.
French government sent to kill him.

In accordance with expansive ideas the patient
may
address the President as his father, or demand access to a

If
millionnairess whose parents are keeping them apart.
confined in an institution, they may for a time ingeniously
conceal their delusions until they find evidences of continued
persecution in their new surroundings, when the fellowpatients appear to them only as accomplices placed there
to aid in their discomfort.
is
Sometimes
confinement
their
regarded as an effort of their persecutors to
tion,
make them
Some
patients submit gracefully to their detenconsidering it but another cross to bear before their
insane.
final rescue
and the proclamation that they are
rightful
few patients even consider that they are being

treated with the utmost consideration and the greatest
rulers.
attention, provided with the best quarters,
every possible privilege by those

injustice
who
and granted
recognize the great
done them.
The course
protracted. The onset is

usually the disease has been in prog-
of the disease
always gradual, and
is
PARANOIA
ress for
some time, even a few
431
years, before recognition.
When once established, the course is slowly progressive,

with a gradual evolution of delusions which are constantly
being further systematized and made to encompass new
environment. Several psychiatrists claim that the course
of the disease presents definite periods according to the
stages of evolution of the delusions. At first there is the
prolonged period of insidious onset, by Regis called the

period of subjective analysis, followed by the persecutory
period with the development of delusions of persecution
with hallucinations, and finally the ambitious period ac-
companied by a
change
of
The
patients
usually are quite orderly, present an unclouded consciousness, and for many years are capable of considerable labor,
personality.
both mental and manual.
After a duration of many years

there appears a moderate degree of mental weakness. Patients become unable to apply themselves, take less notice of
their
environment and
less care of themselves.
In some
cases the disease may seem to be at a standstill for years,

while in others partial remissions occur when the patients
for a time are able to rejoin their families,
but are rarely in
a condition to resume their accustomed occupations.

The diagnosis depends upon the slow onset, the characcoherent, and systematized delusions of persecution
with retrospective falsifications of memory, often associated
with a change of personality, unclouded consciousness,
teristic,
coherent
for
thought,
and absence
of
mental deterioration
many years.
The paranoid forms
dementia prcecox have already

been differentiated from paranoia under the former disease.
of
few cases of dementia paralytica and melancholia may

Dementia paralytica is to be distinsimulate paranoia.
guished by
its
rapid development, the early appearance of
432
emotional weakness, and physical signs.
The conduct
of a
entirely dependent upon the content of the

he
cannot be reasoned with, is persistent in the
delusions;
is
paranoiac
prosecution of his ideas, and is rarely submissive to confinement; while the paretic opposes his retention weakly
and with some stubbornness.

The melancholiac presents a more rapid onset (three to nine
months), a marked disturbance of the emotional attitude,
or intermittently
fear, self-accusations, occasional
an absence
clouding of consciousness,
dences of mental deterioration within the course of
The prognosis
and evitwo years.
of system in the formation of delusions,

of the disease
is
genuine paranoia ever recovers.

The treatment of the disease
very poor, as no case of
naturally limited to the

removal of irritating influences and to confinement in an
institution where systematic routine, with out-of-door life
and ample
exercise,
may
is
ameliorate or ward
off
the condi-
tion of mental weakness.
There are a few cases of paranoia which have been desig1

nated by Hitzig as querulent insanity (Querulantenwahn)
which deserve a brief description here. The psychosis is
of gradual onset,
and usually
legal injustice,
a defeat in court,
some
an unjust award of
arises as the result of
an unfair adjustment of claims,

damages,
in which the patient has been the sufferer.
He refuses to
from
one
carries
the
case
court
to
settle,
another, and finally
loss of property, or
develops an insatiable desire to fight to the bitter end. He

reaches a point where he is unable to view the standpoint
any one else with any sense of justice, and his personal
and desire completely obscure his better judgment.
The statutes appear inadequate, and even the fundamental
He sets aside
principles of the law fail of comprehension.
of
belief
Hitzig,
Ueber den Querulantenwahn, 1895 Koppen, Archiv

Pfister, Allgem. Zeitschr. f. Psy., LIX, 589.
XXVIII, 221
f.
Psy.,
PARANOIA
433
cany on the struggle, solicits symthose who do not side with him.
denounces
pathizers, and
Hearsay and bits of knowledge gathered at random are cited
all
business in order to
as evidence in his behalf, and money is squandered in the

pursuit of justice to the most extreme limits. He cannot
abide by the ultimate decision after all the usual means

of justice have been exhausted.
Failing to appreciate the
needlessness of further struggle, he writes to magistrates,
legislators, consuls, ambassadors, and finally to the President or foreign rulers. Answers to these letters only create
greater embitterment. His letters are long and carefully
particular kind of paper,

times written with colored ink.
upon a
written, usually
The patient
and some-
and often becomes greatly excited in conversation, although at the same time priding
himself upon his ability to exercise self-control.
irritable
is
Consciousness remains unclouded.

served;
Memory is well preoften surprising to see with what

able to quote from law books, to repeat
in fact,
accuracy he
is
it
is
parts of speeches, and to enumerate various dates. Thought

continues coherent, but there is a great tendency to monoto-
nous repetitions of the delusions.

in even a short conversation.
There
is
One seldom misses them
no insight into the condition.
On
the other
hand, the patient is often encouraged in his belief by the

fact that there are always many men, and not a few physicians,
who
will testify to his sanity.
The few
cases of querulency are apt, after a prolonged

to
course,
present greater deterioration than other varieties
paranoia; the content of speech becomes more and

more limited and somewhat incoherent, the irritability
increases, the patient becoms peevish, indifferent, and some-
of
times even stupid.
XI.
EPILEPTIC INSANITY
EPILEPTIC insanity
is
a psychosis based upon epilepsy
which is characterized by a variable degree of mental impairment and by the recurrence of certain transitory mental states,
designated epileptic ill-humor and epileptic befogged states.
The befogged
and
states include pre-
and post-epileptic excitement

deliria, and possibly also
stupor, anxious and conscious
dipsomania.
Defective heredity is the
Etiology.
most frequent
pre-
disposing cause of epilepsy, appearing in eighty-seven per

cent, of cases, while in over twenty-five per cent, epilepsy
1
found in 1070 cases
exists in the parents.
Spratling
taint in fifty-six per
sixteen per cent,

of which displayed parental epilepsy.
He also found
ratios
in
similar
alcoholism
and tubernearly
parental
hereditary
cent.,
notes among progenitors and relatives of

extreme
the
frequency of migraine, headaches,
epileptics
culosis.
Fere
infantile convulsions,
mental disturbances, and deteriora-
All authorities agree that parental alcoholism is a

Wildermuth
prolific source of epilepsy in the offspring.
tion.
considers
disorders,
influence almost as powerful as that of mental

including epilepsy. Other factors in the pro-
its
genitors which predispose to epilepsy are insanity, syphilis,

rheumatism, diabetes, and possibly chorea. Evidences of
congenital defect are frequently found in malformation or

asymmetry of skull, microcephaly, hydrocephalus, the so"
"
called
epileptic p'hysiognomy
(broad forehead, broad and
1
Spratling, Epilepsy
Fe*re*,
and
its
Les Epilepsies, 1890.

434
Treatment, 1904.
EPILEPTIC INSANITY
flattened nose, prognathism, thick lips,
435
and
staring eyes
with wide pupils), feeble-mindedness, precocity, moral delinquency, and sexual perversion.
Among the exciting or immediate causes of epilepsy we
find cerebral palsies, dentition, emotional shocks (fright,
excitement, anxiety, grief),
many
acute infections, meningi-
thermic fever, overwork, gastro-intestinal disorders, disease of heart and kidneys, tobacco, lead, and other poisons,
tis,
carious teeth, foreign bodies in the

intercourse.
Head
such as blows,
ear,
and even sexual
brain lesions (especially

hemorrhages), are frequently assigned as the cause of epiinjuries,
falls,
and in a certain number of cases a direct relation

between them can be traced.
Wildermuth gives their
three
and
as
frequency
eight-tenths per cent., and Heeres
as four and two-tenths per cent.
Spratling says that
"
trauma is more frequently the cause of epilepsy in men
than in women (eight and five-tenths per cent, men three
and five- tenths per cent, women)/' The numerous scars
often found on the head are more frequently the results
lepsy,
than the causes of the malady.

Akoholic excesses are by far the most important causes of
About ten
epilepsy beginning after the twentieth year.
per cent, of chronic alcoholics are thus afflicted. All epileptics present a marked intolerance to alcohol, and its
use by them, even in small quantities, hastens the onset and
intensifies the symptoms of mental disorder.
Many imbeciles
and
idiots
and a few
seniles (thirty-four
hundredths
per cent.) develop epilepsy.

Epilepsy is essentially a disease of youth, convulsions
appearing in thirty-four per cent, of cases in infancy.

Spratling found in ten hundred and seventy cases twentysix and five- tenths per cent, develop under the age of five
436
years; nineteen per cent, from five to nine years; twentyfour and four-tenths per cent, from ten to fourteen years;
and thirteen and
six- tenths
a total of
teen years,
under twenty years.
per cent, from fifteen to nine-
Gowers
and
five-tenths per cent,

found in fourteen hundred
fifty-six
fifty cases that in seventy-four and eight-tenths per

cent, the onset occurred before the twentieth year.
and
As not all epileptics are insane, it is evident

Pathology.
that the pathology of epileptic insanity must be based upon
that of the seizures plus hereditary taint, constitutional
defect, and other factors whose nature and influence are
not yet thoroughly known. There is a wide variation in

views as to the nature of epilepsy, but it is now generally
regarded as a cortical disease which is general and profound.
Gross lesions are of secondary importance and mostly act
as contributing factors. Among the most important gross
changes revealed by autopsy are alterations in the texture

and shape of the skull, old lesions of infantile cerebral
hemiplegia (four to ten per cent.), sclerosis of the cornu
ammonis, porencephaly, encephalic scars, neoplasms, etc.

Wildermuth asserts that thirteen and three-tenths per cent,
of his cases were due to polioencephalitis, and five and
eight-tenths per
maining eighty-three and

"
In the regross lesions.

nine-tenths per cent, of his cases
cent, to other
"
various anaidiopathic epilepsy

tomical changes were found in the brain, which probably
bore some relation to the clinical symptoms. The microcalled
genuine
or
scopic changes thus far found are cortical gliosis

merous cortical cell changes, such as chromatolysis;
we
late epilepsy
litic
of the lesions
and not the
while in
and occasionally syphiand very probable that many
find arteriosclerosis
It is possible
lesions.
and nu-
found in the brain are the results of epilepsy
causes.
EPILEPTIC INSANITY
437
The
periodicity of the seizures may possibly be explained

the
by
apparent tendency in the nervous system to a periodiIf the researches of
cal reaction to any continued irritation.
Krainsky, Cabitto, Agostini, and others can be corroborated,

would seem probable that idiopathic epilepsy is due to a
it
toxic condition arising from faulty metabolism, and that the

immediate cause of the convulsions is the accumulation of
deleterious substances in the blood or a faulty chemotaxis
This theory receives further weight
of the cortical cells.
accomwhich
to
as
drowsipoint
intoxication,
panied by symptoms
ness, headache, nausea, etc.; and also from the fact that
from the
fact that the convulsions are frequently
epileptiform attacks occur in

especially
intoxication,
"
From
from
many
conditions of chronic
alcohol,
the nature of the cortical
cell
and uremia.
changes we have a
lead,
right to expect that the inciting agents will be very active

*
nuclear poisons."
It is now believed that the blood, sweat, urine, and
gastric contents are hypertoxic for some time before, during,
and
after the seizures,
and hypotoxic
in the intervallary
periods, but no definite conclusion as to the sources of this

alteration in toxicity has been reached.
Epilepsy due to
circumscribed lesions, traumatic or otherwise, of the brain,
can hardly be ascribed to toxicity alone. Even if we should

base the known cerebral changes upon a chronic intoxication, we would still need to explain the periodicity of the
accumulation of toxins, and also the hereditary relationship of epilepsy to other mental and nervous
diseases.
On the whole, it seems probable that the ultimate
attacks, the
and
characteristic cause of the symptom-complex epilepsy is

to be found in morbid conditions of the nervous tissues , especially the cortical cells,
1
Spratling,
most
likely
due
Epilepsy and
its
to
chemical changes.
Treatment.
438
Symptomatology.
Epilepsy
some mental deterioration

per cent, this
most
is slight,
unquestionably
produces
in every case, but in about fifty
memory. The
weakmindedness is
chiefly affecting the
striking feature of the epileptic
the slow evolution of psychic processes, external stimuli

arousing only a meagre response in consciousness. In the
majority of cases of epileptic insanity the degree of deterioration once established may remain without marked progress
In a few cases, however, a condition

of profound deterioration may be reached.
Hallucinations are exceedingly infrequent except in the
for years or even
life.
befogged states and anxious and conscious deliria. When

present in the interparoxysmal periods, they generally have
a religious character.
Illusions are quite frequent for a

short period before and after attacks of grand mal.
Consciousness is usually clear and orientation normal in the
intervallary periods, except during the befogged states.
Apprehension of the daily routine

tion
is
is fairly
always somewhat impaired or
Memory
is
keen, but atten-
easily fatigued.
always impaired, sometimes to a great extent.
While prominent events and the ordinary daily routine may

be recalled, the recollection of the general course of life,
whether remote or recent, is more or less hazy. In contrast
to the
defects found in other deterioration psy-
memory
choses, patients are able to express clearly

their remaining
The
narrow
circles of
and coherently
thought.
shows a marked atrophy of the store

In
of ideas with scanty assimilation of new impressions.
conversation and writing there is a strong tendency to detail
train of thought
and
circumstantiality. Their narratives are obscured by

a multitude of data and irrelevant or unessential accessories
which greatly impede the progress toward and development

of the goal ideas.
The connection
is
not
lost,
however, and
EPILEPTIC INSANITY
the goal
439
ultimately reached. The religious content of

another striking symptom, many patients spend-
is
thought is
ing a large part of their time in reading the Bible or in
praying aloud. Patients adhere to familiar paths, and their
vocabulary consists largely of set phrases, platitudes, Bible
The narrowness of thought naturally
texts, proverbs, etc.
leads to a greater prominence of the ego. This is especially
noticeable in the conversation of epileptics, in which they
indulge in praise of self and family, and pay

to personal matters.
much
The imagination is practically

abolished, and epileptics show no
if
inactive,
attention
not entirely
ability to reconstruct or
recombine the materials furnished by old experiences or new

perceptions. They occasionally, however, write verse which
shows an unruly and riotous fancy, as in the following:
"E
is
the eel
is
the finch
who soars to the sky;

who is fond of pie."
Judgment invariably becomes impaired as mental deterioration progresses, but delusions are not common except in some
of the transitory epileptic mental states, when they are
accompanied by hallucinations.
hypochondriacal.
"
even
lost,
and
The
Many
epileptics
true relation of ideas
common
sense," tact,
and
is
become
obscured or
discretion are
seldom displayed. Patients never adequately recognize the

incongruity between their plans and their limited ability.
One man with marked mental and physical defects, whose

schooling had been meagre, gravely proposed to study theology; and another who could hardly name the simplest
flowers desired to become a florist. As a rule, however,
epileptics Imve some insight into their condition, realizing
that they have convulsions, poor memory, and difficulty of
thought.
Among
the most marked
symptoms
are those occurring in
440
even when mental deterioration is not

There is almost always an increased irritability
the emotional
advanced.
field,
manifested by their peevishness, obstinacy, unruliness, also

by frequent outbreaks of emotional excitement as well as
sudden alternations from elation to depression, and the

particularly apt to occur in the proximity
of the convulsions and is easily aroused by alcohol.
Some
"
or
of
an
internal
fear.
anguish,"
patients complain
They
are easily angered, are threatening, quarrelsome, violent, and
reverse.
This
is
dangerous. Usually the finer feelings become blunted, and

there often exists a uniform state of apathy. On the other
hand there are a few patients who
for years always display
a placid, amiable disposition, free from evidences of
irrita-
bility.
Morbid and sudden impulses are frequent and characterissymptoms of epileptic insanity. These are largely due
tic
to increased irritability or lack of self-control. Patients will

attack any one who disturbs them, and often in a blind rage
suddenly
cent
and
inflict
severe
and dangerous
injuries,
even on inno-
inoffensive bystanders, without
any provocation.
These impulses are by no means confined to the pre- or
post-paroxysmal stages, as many suppose, but may arise at
long intervals between the seizures. The wild state of blind
where patients run amuck, striking and assaulting
the characteristic
indiscriminately every one in their range,
a
is
nerve
which
storm
epileptic furor,
may justly be con"
sidered as an
equivalent." These sudden impulses to violence and even homicide render epileptics especially danrage,
are very infrequent, and their

more
so.
accomplishment
The conduct, apart from the stubbornness and morbid im-
gerous.
Suicidal impulses
still
pulses above described, is usually good. Epileptics as a

rule are neat, orderly, and observe the usual convention-
EPILEPTIC INSANITY
alities unless deterioration is
441
quite marked.
Some
patients
display marked sexual excitement, and some are inveterate

masturbators. All epileptics show a diminished capacity
for work, especially
where the higher grades of mental and
physical training are requisite. They may engage with fair

success in simple routine occupations where little or no
initiative is required,
but unless carefully directed and super-
work or leave it unfinished.

The most important physical symp-
vised, are apt to slight their
Physical Symptoms.
toms in epileptic insanity are the convulsions, which may
assume the type of grand or petit mal. In the former there
may be an aura, followed by a cry, a fall, and tonic followed
first, but rapidly
entire
over
the
body. During the convulsions,
extending
which may last from two to ten minutes, consciousness is
totally abolished, but returns gradually within a period of a
by
clonic convulsions, usually localized at
few minutes up to several hours. In status epilepticus there

may be from twenty to even several hundred attacks of
grand mal, without a return to consciousness in the interIn petit mal there is a very brief loss of consciousness
(usually only one or two seconds), either without any con-
vals.
vulsive
movements
or with very slight ones which often
elude observation.
The reflexes are abolished during the convulsions, and in

some cases are not restored for one or more hours. In 1088
observations on male epileptics, Keniston
found that the
normal plantar reflex (flexion of toes, etc.) was present in

both feet immediately after clonus had ceased in forty-five,
and one hour later in two hundred twenty-six, cases; the
Babinski phenomenon (extension of toes with dorsiflexion
of ankle) occurred in one hundred three cases directly after
the seizure, and in one hundred twelve cases one hour later.
Keniston, Journ. of Amer. Med. Assoc., March 21, 1903.
1
442
An extensor response was found in right or left foot in ninetynine and fifty-three cases, respectively, and a flexor response
in right or left foot in ninety-nine and two hundred eleven
cases, respectively, while
in foot
and
a mixed response, that
is,
extension
flexion in the other, occurred in eighty-two cases
and in one hundred forty-seven cases

The plantar reflex was abolished in six hun-
directly after a seizure
one hour
later.
dred sixty cases immediately after the convulsions, and in

three hundred thirty-nine cases one hour later. The kneejerks were active in three hundred ninety-six cases,
moderate in one hundred thirty-seven, and absent in

hundred thirty-nine cases.
The
speech of epileptics
is
often altered
five
and very char-
It is abrupt, with intervals after each phrase,

often drawling, jerky, or strongly accented. During excitement it may be so rapid as to be indistinguishable, were
acteristic.
not for the fact that a few phrases are repeated over and
over again. Tuberculosis and organic and functional dis-
it
eases of the heart are quite frequent, and the pulse rate is
often increased.
Epileptics rarely complain of headache,
and often show an
insensibility to pain
amounting to anal-
while their frequent wounds usually heal rapidly.

Richter found anaesthetic areas in forty per cent, of his
gesia,
cases, general analgesia in
and hemihypaesthesia
in
twelve and two-tenths per cent.,

ten and two-tenths per cent.
are very common. Sleep is often irregular

and muscular strength diminished. Appetite is usually
good, and most epileptics are greedy and gluttonous. As
Paraesthesias
residuals of seizures
we
find scars of all kinds, especially
on the head, broken noses, extensive burns, and absence

of front teeth; and as causal residuals we see evidences of
alcoholic abuses, sequellse of early brain diseases,
or arteriosclerotic alterations, and cranial scars.
syphilitic
We
occa-
EPILEPTIC INSANITY
443
sionally find after seizures small cutaneous hemorrhages,

particularly in the conjunctiva.
In addition to the above general mental and physical

symptoms which constitute the epileptic dementia, there
occur with more or less regularity certain transitory epileptic
mental states, which occur periodically and independently of
external causes.
The most important
of these states
is
the periodical
ill-
humor, which according to Aschaffenburg occurs in 78 per

cent, of epileptics and is characterized by a marked emotional
much involvement of consciousness.

The separate attacks bear an extraordinary resemblance
to each other. The same complaints, the same delusions,
and the same impulses recur. The phraseology of the
patients is definite, the behavior characteristic, and the expression similar. These attacks vary in intensity, and often
come on in the morning. Sometimes the intervals are so
tension without
regular that the time of recurrence can be foretold with

Patients usually awake peevish, irritolerable accuracy.
often
table, fault-finding, threatening, and quarrelsome;
commit sudden and unprovoked
assaults
on the nearest per-
son; break glass or destroy bedding and furniture, and use

profane or obscene language. Very often the emotional
one of anxiety, when the patients complain of

feeling homesick, and low spirited, and of being troubled
with sad thoughts, have presentiments, and express delusions
condition
is
of self-accusation.
Occasionally hallucinations also appear.
At the same time the patients may complain
of feelings of
numbness, pressure in the head, ringing in the ears, and

difficulty of thought.
They are unable to work, wander
about, sometimes remain in bed, and frequently attempt
suicide.
Less often the patients develop a state of expan-
siveness or ecstasy.
They then run about with
glaring eyes
444
and happy countenances. They shout, throw things about,

and get into all kinds of trouble, tease their mates, pray
loudly, and express expansive religious ideas.
Occasionally
there is a flight of ideas. Furthermore there is great emotional
Some patients
irritability with a tendency to aggressiveness.
rapidly develop a condition of marked excitement. Sometimes the patients develop a delusional state with emotional
and anxiety and also occasionally accompanied

by hallucinations, which condition might be termed a
irritability
paranoid condition.
While the ill-humor usually occurs after a seizure, it may
precede it, in which case the convulsion generally clears the
mental atmosphere. The attacks rarely last more than a

few hours, but may persist for a week or more. Abatement
is gradual, and is often followed by a feeling of complacency
or well-being. In some cases the hallucinations and delusions may persist with little change for weeks or months,
simulating closely
but
praecox,
found in dementia
certain conditions
finally the
hallucinations
and delusions en-
tirely disappear.
Befogged states represent the second large group of transitory epileptic states, and are characterized by a more or less
profound clouding of consciousness.
pre- and
post-epileptic insanity,
These states include
psychic epilepsy
stupor, anxious delirium, conscious delirium,
epileptic
some cases
of
somnambulism, and possibly dipsomania. The befogged states

are sometimes preceded by the transitory states of ill-humor
Alcohol may predispose to them, even when
just described.
taken in very moderate quantities.
Here all sorts of morbid sensory
Pre-epileptic Insanity.
impressions
vision,
may
parsesthesias,
arise,
flashes of light,
impairment of
or strange sounds, peculiar odors, and

which are not to be confounded with the
indefinite
EPILEPTIC INSANITY
individual aura,
ideas,
falsified
when such
445
There may be fixed

monotonous repetitions of
exists.
identifications,
words or phrases, involuntary or grotesque movements,

and imperative impulses, as to strike, destroy furniture, or
sometimes a few minutes or even
In a short time
kill.
consciousness becomes clouded, and the conseconds
vulsion begins. In a few cases the latter passes over into
a pronounced dreaminess lasting for hours or days.
It is
Post-epileptic Insanity.
more common and
is
char-
by deep dazedness after the seizure, lasting for

hours or even days. Patients do not understand questions,
acterized
speak confusedly (paraphasia), are completely disoriented,
wander aimlessly about,
collect all obtainable objects,
and
even drink their urine. While active sensory disturbances

are undoubtedly present, no account can be obtained from
the patients, who have complete amnesia of all that has
happened. As a rule, they recover their normal mental

and emotional attitude very gradually.
Mental and emotional disturbances
Psychic Epilepsy.
very similar to the above
appear in the intervallary

of
the convulsions, and are
periods, entirely independent
then called
ditions are
may
"
equivalents," or psychic epilepsy. These conby no means rare,, and are frequently observed
in hospitals.
They
are
have seizures at long
more
liable to occur in patients
intervals.
The
who
essential feature of
psychic epilepsy is the disturbance of consciousness. Patients

are confused, move and act in a mechanical or automatic
manner, and often present evidences of

tions,
and
delusions.
They wander
illusions, hallucina-
aimlessly about,
and do
not appear to recognize any one, but will sometimes reply

incoherently to questions. Occasionally they assume fixed
or peculiar positions, or gaze steadily at one point. In some
instances they display a heightened excitement,
and again
446
a gloomy stupor, during which they may masturbate, expose their person, or attempt sexual assaults. Patients
have been known to set
fire
to their bedding or furniture for
The numerous
trivial purposes as boiling coffee, etc.
criminal acts, such as theft, arson, assaults, and even homicide, committed during these periods demonstrate the ex-
such
treme importance of the recognition of psychic equivalents

in their medicolegal aspect.
The
history of previous attacks
of grand or petit mal, even if very infrequent, the senselessness of the actions, with utter absence of motive or attempt
at concealment, and either complete amnesia or only a very
hazy recollection of what has happened, should make the

diagnosis clear. These attacks usually last only a short
seconds or minutes,
an hour or more.
time,
Under the head
but occasionally continue for
of psychic epilepsy should be included
some
Patients nocases of somnambulism, occurring in epileptics.

in
of them.
which
are
front
those
directly
only
objects
tice
The
Movements
closed, half-opened, or staring.
there
of
but
evidences
may be
automatism,
usually display
traces of deliberation and purpose, as in avoiding obstacles.
eyes
may be
Sometimes higher psychic fields are involved, and patients

may carry on long conversations, compose poems, or transact
business. Next morning they do not remember what they
have done, but may complain of lassitude, stiffness, or soreness.
Here the clouding of consciousness is

Epileptic Stupor.
intense and prolonged.
Patients may eat, speak, or perform certain mechanical movements, but always as if dreamSometimes the eyes
ing and without clear understanding.
are closed, or the face dazed or staring. The same attitude
is maintained for hours or even days, and the expression
justifies
the inference that confused terrorizing delusions
EPILEPTIC INSANITY
447
dominate the emotional sphere, although occasionally the

demeanor indicates happiness or religious ecstasy. Patients
show absolute
indifference
to
their
environment,
never
answer questions, remain in bed, and soil themselves. They

sometimes show active resistance if disturbed, may make
sudden impulsive attacks, and instinctive suicidal attempts
are not infrequent.
is
and
blunted,
Nourishment
The
reflexes are abolished, sensibility
in single cases
is
often refused,
temporary catalepsy
is
seen.
either wholly or partially.
Epileptic stupor usually lasts from one to two weeks, but

is longer.
Recollection of the
in severe cases the course
events
is mostly lost.
Improvement is generally gradual,
but in a few cases the confusion may disappear in one day.
Where attacks
are repeated and prolonged, patients may

a long time dull and inattentive.
Anxious Delirium.
This form is more frequent than
remain
for
stupor and may occur independently of seizures. The mental

disturbance is profound. The attack develops suddenly,
and may be preceded by very brief periods of

characteristic sensations, and numbness, or by
ill-humor,
fixed
and
regularly recurring hallucinations, as red objects, flames, etc.

Apprehension is dulled, surroundings are changed, and
orientation
is
lost.
usually terrifying
The
and delusions are

be
must
patients
punished, must die, are
hallucinations
surrounded by devils, animals, or throngs of people who

come out of the walls or floor. They wade in blood, their
parents are perishing, the house is blown into the air, or
everything
carries
is
them
Sometimes God or Christ appears and

sinking.
in splendid chariots to heaven, but these trans-
and the predominant tone of their

and dread. Patients are impelled to
ports are only transitory,
emotions
brutal
is
and
one of fear
incredible outrages, as cutting
or children, shooting, stabbing, etc.
up their parents
They run away to escape
448
the horrors which confront them.
With
flushed faces, either
howling and shrieking, they rage furiously, with

prodigious strength, destroying everything within reach.
silent or
The duration
to two weeks.
of anxious delirium varies
from a few hours
Sometimes consciousness clears up suddenly

after a long sleep, but usually gradually, so that transitory
hallucinations, delusions, and normal ideas are mixed together in a characteristic manner. There is no recollection
of events occurring during the height of the delirium.
a rare form, which either

follows a seizure or appears as a psychic equivalent. Patients
appear from their conduct to be conscious, but in reality
consciousness is greatly clouded, while numerous illusions
Conscious Delirium.
This
is
and hallucinations may inspire false ideas of danger. Expansive ideas are not uncommon. Answers to simple questions are coherent and relevant, but the whole demeanor, if
closely observed, discloses some confusion and disorientation.
The disposition is irritable, usually anxious, but sometimes
elated, and delusional ideas often lead to impulsive acts.
Legrand du Saulle reports the case of a merchant who, on
suddenly recovering from an attack, found himself on the
Others have committed, with seemingly
unclouded consciousness, senseless and even criminal acts
way
to
Bombay.
indecent assaults) without any insight into their significance. Attacks of conscious delirium may last for days, weeks, or even months,
(thefts, arson, rebellion, desertion,
and there may be a
series of attacks
separated by short
intervals.
Dipsomania in many respects resembles epilepsy, as it

presents an apparently paroxysmal and periodical impulse
to senseless alcoholic excesses.
Among the prodromal symp-
toms are noted uneasiness, anxiety,

weariness of
life,
fear,
despondency,
increased irritability, a feeling of heaviness
EPILEPTIC INSANITY
449
in the head, anorexia, insomnia, and occasionally sexual

excitement. Very rapidly after these manifestations there
appears an impulsive and irresistible desire to obtain relief,

"
"
which is found in a mad rush for liquor. Some patients
develop a typical epileptic befogged state, in which they become abusive, aggressive, noisy, and undertake foolish journeys.
One man had attacks once
in
two
years,
when in the
space of two days he would drink several pints of whiskey,

ultimately becoming completely unconscious, and often, on
coming to his senses, finding himself in strange places.
After several of these attacks, he arranged that friends should
take him to a hospital on the

dromes.
Some dipsomaniacs
first
appearance of the pro-
present no typical epileptic disturb-
ances, but in their attacks fall suddenly into a condition

resembling inebriety, in which they continue without in-
day and night
to drink large quantities of

or
beer, wine, gin,
spirits, until they have spent their last
cent, and even sold their clothing to obtain means for
During these attacks
gratification of their morbid appetite.
terruption
intoxication
is
and patients
seldom complete, but consciousness
is
clouded,
retain only a hazy recollection of a few events
and an
and
somegradual,
of their debauch, but often manifest deep contrition
abhorrence of alcohol.
Convalescence
is
times accompanied by nausea, anorexia, gastric catarrh, unsteadiness, and tremors, while a few cases present symptoms
accompanied by delirium and hallucinations.

The attacks of dipsomania may recur without any external
cause, and in the intervals, which may last for weeks, months,
of collapse,
or even years in a few instances, patients have no craving

for alcohol, and either totally abstain or drink very moderately.
There are
many
from the
Some patients mani-
transitions or variations
characteristic picture of dipsomania.
450
a disposition similar to that of epileptics, and a few

perhaps present during life only one instance of an epileptic
fest
befogged state accompanying an attack of inebriety.
The diagnosis of epileptic insanity is generas we can establish the existence of the
as
soon
ally easy
It should, however, be differencharacteristic convulsions.
Diagnosis.
tiated from hysteria, dementia paralytica,

tonic form of dementia prsecox.
In
hysterical
insanity consciousness
is
and the cata-
less
deeply dis-
turbed in the seizures, and we almost never see sudden

voluntary
The
falls,
in-
serious injuries, or biting of the tongue.
seizures are also specially induced
by external
influences,
as mental emotions, physicians' visits, etc., and may be curtailed or suddenly aborted by very lively excitement or
strenuous treatment. The development is more diversified
than that of the epileptic seizure, which is always uniform.

In hysteria tonic and clonic muscular contractions of the
convulsions of the diaphragm, opisthotonus,
jactitation, rolling on the ground, somersaults, lively moveentire body,
ments of expression (dramatic and passionate attitudes),

alternate even in the same attack, and consciousness is never
Dilatation and immobility of the pupils, usually
considered an important characteristic of epilepsy, have
abolished.
recently been found in hysteria also.
We
find in hysteria
rapid changes
disposition, and
dependence on external influences, while in epilepsy there
is a rough irascibility, a limited waywardness, an inde-
extravagant
caprices,
of
pendent periodicity, and a prominent ill-humor. Mental

weakness is more frequent and pronounced in epilepsy.
In epilepsy coming on in middle life, we must consider the
which sometimes begins

with epileptiform seizures. Here the consideration of the
other symptoms, such as impaired pupillary reflex and
possibility of dementia paralytica,
EPILEPTIC INSANITY
451
inequality, characteristic speech disturbances, ataxia, incoorWhen, howdination, etc., will soon clear up the diagnosis.
ever, the epileptiform attacks occur at long intervals,
are accompanied
and
by one or more of the above symptoms, we
should be prepared for the possibly gradually developing

symptoms of dementia paralytica.
The
initial
been mistaken for the

stage of the catatonic form of dementia prcecox. In
epileptic befogged state has
the latter
we
find negativism, passive resistance, senseless
and correct execution of commands, eccenand

tricities,
stereotypy, with absurd acts, and less disturbance of apprehension and orientation. In epilepsy
there is anxious resistance with indifference to orders, and
answers, rapid
uniformity of conduct, while there are frequent assaults,

atrocities, and attempts to escape.
Special weight attaches
to the previous history and the proof of separate attacks of
vertigo or syncope, periodical ill-humor, and probable night
attacks, as evidenced
by occasional enuresis, injuries to the

and
or headache in the morning.
severe
lassitude
tongue,
The diagnosis of the befogged states, when only one convulsion has been observed during
one, but only a brief syncope, presents
we must remember that

portant
symptom
or perhaps not even
life,
some
difficulties;
while the convulsion
of epileptic insanity,
it
may
but
a very imbe absent or
is
"
replaced by an
equivalent." Hence the periodicity of
the attacks, clouding of consciousness, morbid impulses,
crimes committed without motive or attempt at conceal-
ment, amnesia, and rapid course will facilitate the diagnosis.

This depends essentially on the cause of the
Prognosis.
When dependent on gross

epilepsy and the time of onset.
brain lesions, recovery is out of the question, and the mental
weakness often progresses to complete deterioration. When
following head injuries, some recoveries have occurred, and
452
in
cases decided
many
and long-continued improvement has
resulted.
Genuine epilepsy
rence
is
is
common
spontaneously, but recurprolonged, and in the interval there
may disappear
if life is
some mental dulness with transient
usually
ill-humor.
where the befogged

states, especially stupor, have occurred, if they have been
at all frequent. In some cases of anxious delirium death
Improvement rarely occurs
in
cases
occurs from exhaustion.
Conscious delirium is not dangeranxious

delirium, if recurring at short
life,
intervals, tends to hasten the progress of deterioration.
ous to
but, like
In epilepsy arising late in
life
the outlook
is
very un-
On the other hand, in alcoholic epilepsy treatoften successful in effecting a cure, or at least great
improvement. On the whole, while in some cases patients
may improve sufficiently to go home, especially where the
favorable.
ment
is
disturbance
is
largely in the emotional sphere, the prognosis
unfavorable, and patients should be

subjected to prolonged observation and treatment before
one assumes the risk of discharging them. This is all the
of epileptic insanity
more
is
may occur without any

and
thus
the
becomes
a danger to the comseizures,
patient
munity. As far as life is concerned, we must remember
that serious and even fatal injuries may result from accidesirable as attacks of furor
dents occurring during the convulsions or from the development of status epilepticus. Worcester found that sixty per
cent, of epileptics die as the result of their seizures.
Treatment.
As
far as the medical treatment of epileptic
can be done except to attend to

bodily needs and combat any unfavorable symptoms which
may arise. On the other hand, moral treatment, by which
insanity
is
is
meant
concerned,
little
suitable occupation
and
diversion, out-door
life,
helpful suggestions, educational efforts to retard the progress
EPILEPTIC INSANITY
453
and conserve what mental equipment is

left, is of the highest value and an absolute necessity.
Every one who possesses a remnant of physical or mental
power should be obliged to do something. Occupation should
be light, safe, avoiding high or dangerous places, varied, and
of deterioration
with ample intervals of
and wholesome, and
all
Diversions should be simple

reading should be carefully selected,
rest.
consisting largely of history, biography, light essays, stand-
ard novels, and religious subjects which would help toward

right living and avoid all exciting or controversial points
which might intensify the
religiosity to
which almost
all
epileptics are prone.
The treatment of epilepsy itself should be based on wellknown principles. Nutrition should be fostered by careful
attention to the alimentary system. The diet should be
regulated,
and may
consist of fruits; cereals in moderation
and thoroughly cooked ; eggs, breads, milk, cocoa, chocolate,

and a minimum of tea and coffee; simple puddings, such as
rice, farina, and custard; fish and a moderate amount of
meat, at noon only. The supper should be very light and
taken at least two hours before retiring. All meals should
be regular, and patients should be carefully supervised to
"
"
insure thorough mastication and prevent
food.
bolting
The reduction of salt in food has been advocated, not only to
diminish the irritability arising therefrom, but to enable us
to materially decrease the amounts of bromids prescribed.
method diminishes by one-half the chance

of bromism.
Toulouse and Richet have introduced the
hypochlorization method, which consists in using sodium
It is said that this
bromid
in place of ordinary salt, ten grains
being equal to
The kidneys
twenty
of the former
grains of the latter.
require attention,
and the
secretion of urine
should be stimulated by a free use of water.
The
skin
454
should be kept in good condition, and occasional hot baths

employed to induce perspiration. If eye strain or other
ocular symptoms are present, they should be remedied.
The teeth and mouth must be kept
in a healthy state.
It is very important to insist on complete and permanent

abstinence from alcohol in all cases, and not merely in alco-
holic epilepsy
and dipsomania.
less intolerant of its effects,
to be gained
from
it
more or
and emoand nothing
epileptic is
very severe mental
tional disturbances often result

is
Every
in
from
its use,
case.
any
While innumerable remedies have been used to control or
abort the seizures, their utility is somewhat doubtful, since

the convulsions are practically safety valves, which allow the
Unless the cause can be removed, it

is perhaps better to allow the insane epileptic to have his
Neverthefits, as they often clear the mental atmosphere.
elimination of toxins.
and lay opinion, it is

advisable in every case, at the beginning, to administer the
bromids, either singly or in various combinations, with
proper precautions, until after due trial we can decide from
less,
in the present state of medical
condition of each patient

mentally, emoand
whether
or
no
it
is best to contionally,
physically
tinue their use. They should be given at the start in very
the general
small doses (6 to 8 grains) three times daily, after meals, in

plenty of water, gradually increasing the amount until the
point of saturation is reached, which is indicated by the disappearance of the throat reflex. Then the dose, which varies
with the individual, should be reduced more or less gradually

we establish a norm which can be continued for a long
until
In
time, even years, with occasional short interruptions.
some cases the epileptic disturbances disappear, not even
is suspended, and we may
the
case
as
cured.
It must be borne in
perhaps regard
returning
when the medicine
EPILEPTIC INSANITY
455
mind, however, that in a certain number of cases the seizures

cease spontaneously without any treatment, not to recur
for years,
if
ever.
Hence we must not attach too much im-
portance to the curative power of the bromids.

Should bromism occur, as evidenced by acne, digestive
disturbances, bronchial disorders, cardiac weakness, increase
of the reflexes, anaesthesias,
etc.,
impairment of memory, stupor,
the bromids should at once be discontinued and an
free and
and supporting treatment instituted,
of
bowels
and
evacuations
bladder, promotion of
regular
normal skin action, and the use of digitalis and strychnin
eliminative
and decreasing
bed and a simple,
in small
rest in
Among
doses,
supplemented by absolute
easily digested diet.

the other countless remedies employed to control
may be mentioned argenti nitras, brom-ethyl,

oxid
of zinc, borax, adonis vernalis, and the Flechsig
atropia,
treatment by a regular course of opium in increasing doses,
the seizures
followed by bromids, with rectal lavage, and strict confinement to bed. While all these have given satisfactory results
in
some
none are so generally useful as the bromids.

status epilepticus, which is comparatively infrequent
cases,
When
the insane, occurs, compression of the carotids should

be tried if the arterial tension is very strong. Full doses of
among
bromid, opium, and chloral in combination
may
be given at
two hours, by mouth or rectum, and inhalation

Combat exhaustion and
and treat all complications promptly, especially
intervals of
of ether or chloroform be tried.

collapse,
supporting the heart.
Treatment directed to the causes of epilepsy is not promising in insanity, as the disease has been of too long duration.
Hence head operations are usually contra-indicated. The
time to operate for trauma,
etc., is
or immediately thereafter.
The
when the
lesion occurs,
prevention of epilepsy can
456
only be secured by preventing marriages of the epileptic,

insane, defective,
Finally, in
and
alcoholics.
view of the
liability to assaults
and
injuries to
or others, every epileptic should be under constant surveillance at all times, night and day.
self
THE PSYCHOGENIC NEUROSES
XII.
NEUROSES
commonly designated as a group of

by changing and transitory nervous
are
characterized
diseases
disturb-
ances, to be distinguished from psychoses by the fact that

the symptoms do not involve the mental field. But in prac-
psychoses without nervous symptoms or neuroses without mental symptoms are not encountered. Among the
neuroses there is a distinctive group of cases, the individual
tice
symptoms
of
which are
of a purely psychogenic origin.
This
group, which comprises hysterical insanity, traumatic neurosis, and dread neurosis, is in general characterized by
a more or
less
marked
hysterical constitution, the
numerous
manifestations of which are seen on every side. While

are
traumatic neurosis and dread neurosis
closely
related to hysterical insanity, they are, however, characterized
clinical
method of development, by
a different course.
and
symptoms,
by a
different
different
HYSTERICAL INSANITY*
A.
to give a perfectly satisfactory

definition of hysterical insanity, it may be described as a
Although
it
is
difficult
Moebius, Schmidt's Jahrbiicher, 199, 2, 185 (Literatur) Neurologische

Monatsschr. f Geburtshilfe und Gynkaologie, I, 12 Pitres,
;
Beitrage, I
Lemons cliniques sur Thysterie et Thypnotisme, 1891 Gilles de la Tourette, Traite clinique et therapeutique de Thysterie, 1891; Janet, Der
Geisteszustand der Hysterischen (die psychischen Stigmata) deutsch von
Kahane, 1894; Sollier, Genese et nature de Thysterie, 1897; L 'Hysteric
et son traitement, 1901
Ziehen, Eulenburgs Realencyclopaedie, 3. Auflage; Krehl, Ueber die Entstehung hysterischer Erscheinungen Volk;
457
458
neurosis in which mental states produce manifold physical

symptoms with extraordinary ease and facility.
Hysteria develops upon a morbid constitutional basis.

Defective heredity occurs in seventy to eighty
An equally important factor is the influcent,
of
cases.
per
Etiology.
ence of defective education and training. Other factors are

trauma, shock, acute and chronic diseases. Mental stigmata
are often recognized in early life ; as, irritability, waywardness,
indolence, talkativeness, undue piety, and sudden and rapid
changes of emotional attitude. Sometimes such physical
disturbances as chorea, headache, and loss of speech have

been noted. More than two-thirds of the patients are
women.
In children, 1 in
whom the
is more prevalent among

more
males, special symptoms
prominent, as mutism,
reflex convulsions, paralyses, and attacks of screaming,
convulsive coughing, and silly befogged states (Chorea
disease
are
These symptoms are easily produced by physical

more especially by emotional disturbances, and
but
injuries,
not infrequently result from psychical infection (school
Magna).
epidemics).
Poverty, seclusion, and faulty physique favor
their development.
Hysteria does not often develop in adult
life,
although the
symptoms may become more prominent during the climacterium. The role played by the disturbance of the female
sexual organs in the production of the disease is not clear.
On the one hand, it has been observed that disturbances of
these organs may produce severe physical and mental disorders without creating hysterical symptoms, that the
manns
klinische Vortrage,
Klinik, VI, 2, 155, 1901
Neue Folge, 330, 1902; Fuerstner, Deutsche

Jolly in Ebstein u. Schwalbe, Handbuch der
praktischen Medizin.
1
Bruns, Die Hysteric im Kindesalter, 1897 ;
Psy., IX, 321.
Sanger, Monatsschr.
f.
459
disease sometimes appears long before puberty, and finally

that it develops in individuals with normal sexual organs.
On
the other hand,
it is
known
that uterine disturbances
frequently exist and are a source of complaint, and that the

even minor uterine disorders leads to a marked im-
relief of
provement. It seems probable, therefore, that disorders of

the female sexual organs act only as prominent exciting
causes.
The true nature of the disease is still unPathology.

known. A short and satisfactory explanation is that hysteria
a congenital morbid mental state whose chief characteristic
lies in the fact that, as Moebius expresses it, physical symp"
toms are produced by ideas." To this might be added that
is
these ideas are strongly emotional, and, indeed, also indefiThis would account for the fact that the physical
nite.
symptoms do not always correspond
to the character of the
stimulus or to the content of the ideas, that they can appear

in fields not accessible to the influences of the will, and some-
times are not even noticed by the patients. The internal

between sadness and tears is no better understood
relation
than that between fright and hemianaesthesia.

cause a movement of the bowels and whitened
Terror can
hair, just as
hysteria can produce edema and disturbances of the heart's

action.
Even clouding of consciousness may be brought
about by states of feeling. While it must be confessed that

this is not an entirely satisfactory explanation of the nature
of hysteria, yet it seems probable that increased emotional
excitement and the morbid prominence and duration of the
involuntary expressions that accompany it play an important role in the production of the disease.
There
is
no known anatomical pathological basis for the
disease.
Symptomatology.
Apprehension
presents
no
striking
460
On
disturbance.
uncommon
many patients exhibit an

are
they
very keen in the per-
the contrary,
sensitiveness;
ception of details in the environment, and especially any

A few patients are gifted along certain lines, while
defects.
others are dwarfed mentally.
and
vivacious
bility
and lack
Although the patients appear
bright, close observation discloses distractiof
sound judgment.
They are easily attracted
by anything new
or striking, are deeply impressed by show,

become the clients and champions of the most recent phy-
sician,
and adopt
weakness
peculiarities in dress
are eager for sensation,

all
and ornament.
is observed especially in the field of religion.
and take pleasure
in gossip
This
They
and in
sensuous enjoyments.
Memory
balanced.
correctly
is
generally accurate, yet
it
is
often not well
Furthermore, what is perceived is not always

In some cases there is a marked
interpreted.
tendency not only to amplify events of the past, but even to

distort
them by pure
Patients will rehearse
fabrications.
startling personal experiences and, in order to
make
their
more credible, will present marks of violence,

which they themselves have made. In such cases there is
no doubt that the patients consciously deceive in order to
arouse sympathy or to cause a sensation. But in the minor
tales all the
from the truth shown by the average hys-
variations
terical patient it is difficult to
say
how much
is
intentional
and how much
is* due to the subjugation of

a
memory by lively imagination. In some cases, no doubt,
the imagination dominates entirely all thought and action
deception
without creating the picture of a real delusion.

Disturbances in the emotional attitude are very important
symptoms. The fluctuation of the feelings determines to a
large extent the whole
influence
is
mental
life
of the patient.
Their
stronger than rational deliberation or moral
461
Patients are excitable, and take an active perprinciples.

sonal interest in everything around them, are extraordinarily
sensitive, and exhibit a tendency to outbursts of feeling on
slight provocation.
Occasionally there
is
heightened sexual
excitement, but, on the other hand, there may be an absence

of all sexual feeling.
Frequent and abrupt changes in the
emotional attitude are also
characteristic.
One never
find the patients ; they pass abruptly from

a state of merriment into passionate anger at one moment
they may be distastefully sentimental, at the next crotchety
knows where to
and
antagonistic.
This increase in the emotional irritability is perhaps a

cause of the concentration of thought upon self. Some patients even seem to take pleasure in meditating upon and
busying themselves over their ill-health.
Thus numerous
ideas originate and dominate thought.

emotional
Moreover,
depression has a more powerful influence than in the normal person in producing all sorts of
physical ailments. The ease with which this influence is
hypochondriacal
and the variety
symptoms
are especially char-
acteristic of the hysterical constitution.
Insignificant feel-
excited
of the
ings of discomfort receive
undue
attention,
and may even
Real complaints are greatly

the
exaggerated by
lively imagination of the patient until
hypochondriacal ideas are evolved. Genuine pain arising
create sensations of injury.
from a
definite lesion fails to disappear
with the removal of
the cause, but continues indefinitely, and
more widespread.
with menstruation
may even become
The headache and backache
may
grievous and agonizing
be the
foci
coincident
from which there arises a

symptoms of which the
condition, the
on every possible occasion.

Patients develop a most remarkable attitude toward their
disease. They believe that it is an object of distinction, and
patients rehearse in all detail
462
even become proud of their invalidism. This is also evident in their failure to cooperate in treatment. Although
complaining bitterly, they lack all feeling of personal responsibility in carrying out treatment, and may even stubbornly refuse to
assist.
However, any new or striking
method
of treatment, although it may entail some suffering,

often will be undertaken for the sake of notoriety. Many
deny themselves the pleasures of life, and continue to attend entertainments, to visit and receive company, in spite of the claim that their suffering is even
refuse to
enhanced by such endeavors.
Many
terrible
fears,
patients complain particularly of mental suffering :

thoughts that constantly torture them, ungrounded
the
memory of
the failures of their
lives, etc.
These
are repeated over and over at every opportunity with great

show of emotion, but not without emphasizing their own
heroic struggle or martyrlike submission.
Occasionally they
wish they were dead and utter threats of suicide ; sometimes
make melodramatic and even absurd
attempts, such
as tying a ribbon about the neck or jumping into shallow
water.
they
The numerous hypochondriacal complaints necessitate

constant medical attendance. Some patients develop a
On the
state of absolute dependence upon one physician.
not unusual for patients to change physicians frequently, to visit celebrities and ask for many conother hand,
it is
They often fall into the hands of quacks who

them by offering some wonderful cure. These cures,
sultations.
gratify
if
effected, are usually as transitory as
An
exaggerated self-consciousness
is
they are striking.

a common symptom.
Hysterical patients are markedly self-conscious, and display

a corresponding lack of regard for the interests of others.
They
perceive with morbid acuteness any encroachment
463
upon their own comfort, but accept the most extreme sacrifice on the part of others as a mere matter of course.
They
are always exacting beyond reason, dissatisfied with the
best efforts of others, and deeply grieved over neglect or lack
of sympathy. The insatiable cravings of many hysterical
patients develop out of this heightened self-consciousness.
Dissatisfied with what they have, they are constantly asking
new
new
different
furniture,
clothing,
food, etc.
quarters,
It is often surprising to see how undeserving patients successfor something new, usually objects difficult to obtain,
new
fully establish intimate relations
with churches,
and well-meaning philanthropists, who

unreasonable demands.
the family.
In the volitional
an increased
societies,
most
These patients regularly tyrannize
gratify the
the most pronounced symptom is

Patients
susceptibility to external influences.
field
yield readily to all sorts of influences, quickly become enthusiastic in any cause and just as quickly lose interest.
In
contrast to this extraordinary pliancy of the will to the most

varied and insignificant conditions there is frequently observed the apparent opposite state of wilfulness. When
"
get something into their head," they are most
patients
obstinate and headstrong in their purpose. Some subject
themselves to great discomfort and pain, even torture themselves, and refuse to eat or speak without any apparent
In reality these apparently contradictory states of
reason.
the will arise out of the pliancy of the will to accidental influences, whether they are external impressions or personal
The unreasonable and impulsive conduct

hysterical patient arises from the same source.
fancies.
of the
Consequently, in conduct the patients are unstable and

and change rapidly from one act to another without
erratic,
sufficient reason.
Because they lack uniformity and per-
464
sistency, there develops
more or
less restlessness, which
stands
out in strong contrast to their physical weakness and helplessness.

They have a pressure to do something, to take
part in something, to distinguish themselves, to do some misIn manner they are at
chief, and they long for adventure.
times vivacious and frank, at others reserved and bashful,

or, again, silly and sentimental.
They are demonstrative
and often express themselves in the most exaggerated terms.

Their vehemence of expression by no means always corresponds to the intensity of their feelings, as the latter often
rapidly from one state to another. Patients
characterize their own condition by such expressions as
"
"
"
Most horrible!" Excruciating
"Inexpressible!" and in
fluctuate
depicting their suffering it is not unusual for them to add

color to the description by copious weeping or even fainting.
In spite of their intense misery, the thought of self-enjoy-
ment usually remains

several sheets of her
in evidence.
home
One
patient, after filling

letter with the most horrible self-
execrations, closed with the request for macaroons.

The capacity for employment is impaired; the patients
have no disposition for earnest and strenuous occupation,

lack perseverance, are weak and easily exhausted, and always
that they must spare themselves. On the other hand,
feel
they pass
much time with
trifles,
arranging and rearranging
pretty ornaments in the rooms, and dillydallying with their

toilet and personal adornment.
The physical symptoms of hysteriPhysical Symptoms.

cal insanity are wholly functional and are often referred to
"
as
stigmata." They consist chiefly of different degrees of
paralyses of a single limb, astasia abasia, choreiform movements,
contractures,
aphonia, impairment of
ances,
including
and general convulsions,

speech, numerous sensory disturb-
localized
parsesthesia,
anaesthesia,
hypersesthesia,

and
fits,
visual disturbance;
globus clavus, singultus, fainting

obstinate vomiting, disturbance of
Anaesthesia of
anomalies of secretion.
of appetite,
loss
respiration,
the
465
and
mucous membrane
of the
mouth and
of the cornea is
regarded as a characteristic symptom of hysteria. Finally,

It is characteristic of
disorders of sleep are very frequent.
all
these
symptoms that they do not
follow anatomical
and
physiological rules, but are dependent in their appearance,

Hemipersistence, and departure upon psychic influences.
crania or convulsive
movements can often be made
to dis-
appear by pressure upon the eyeballs. Contractures or

paralyses may be made to vanish by firm pressure over the
ovaries or in the hypogastric region, or by an unexpected
dash of cold water upon the face or body. Patients who
for years have been bedridden, reduced to a skeleton by
fasting,
and
secretly inflicting
wounds upon themselves
to
may be immediately transformed into entirely

different individuals by a sharp command, new environment,
incite sympathy,
some sudden freak. But such transformations are usually

short-lived, and the patients relapse either into their former,
or a still more distressing, condition. Furthermore, the
or
symptoms sometimes disappear when the
patients believe
themselves unobserved or are left alone, only to reappear as
soon as their illness is referred to, or when confronted by the
physician.
These various mental and physical symptoms just described

are characteristic of the hysterical personality and constitute
the
groundwork upon which
there develop other characteristic
transitory hysterical states.
Of these transitory hysterical conditions, the befogged

states are the most prominent.
They are characterized by
a marked clouding of consciousness, of varying duration, and
either follow, take the place of, terminate in, or are interrupted
2H
466
by,
a convulsion.
throughout
its
In the simple hysterical attack there is,

entire course, only a clouding and not a com-
plete abolition of consciousness. The patients usually sink

to the floor without injuring themselves, and during the
attack often show in one

fluenced
by
way
external stimuli.
or another that they are inThe attack may consist of
simple fainting, or may be accompanied by pronounced

convulsive movements. The convulsive movements do not
seem more
and
at
times
even
complicated
appear purposeful. The
patients twist themselves about, groaning and screaming,
they roll over and straighten out, strike their feet on the
floor, or roll themselves up like a ball; at the same time there
is a spasm of the diaphragm, marked slowing of the pulse,
flushing of the face, and rolling of the eyes.
Very often the
back is so strongly bent that the patient's body rests on the
bed only at the back of the head and at the heels, forming
the arc of a circle. At intervals the patients may turn somer-
show
fixed rigidity or uniform trembling, but
suddenly leap up, clutch at various articles, or cling

to something; they may also make grimaces. Occasionally
they exhibit delirious states, in which they imagine that they
saults, or
are passing through some exciting experiences and make

all sorts of active movements.
Often the patients repeat
some actual occurrence in all its details, but usually in a

theatrical manner.
Sometimes the content of the delirium
when the
patients find themselves in

some fearful predicament or a state of ecstasy with heavenly
visions and feelings of joy.
is
wholly
fictitious,
All of these different
symptoms
of the hysterical attack
may succeed each other in various ways. Frequently, they

are repeated over and over in a regular order. The delirium
may be
interrupted by fainting spells or convulsions. Sometimes the physical and mental symptoms of the attack
467
occur separately, and at other times combined in various
ways.
Following the attack, the patients lie quietly with relaxed
limbs, occasionally showing a slight tonic rigidity, breathing
and with a slow pulse rate, the eyes turned upward

or rotated laterally. They are irresponsive, except to a
powerful stimulus, such as an electric shock or sudden terror,
which sometimes entirely arouses them. Such a condition,
interrupted by occasional convulsions and short lucid intervals, during which food can be taken, may last from a few
quietly,
hours to three weeks.
This condition has been termed hys-
terical lethargy.
Sometimes the befogged state simulates ordinary sleep.

The patients become drowsy, the eyes close, the limbs become relaxed, as in a profound sleep, and the respiration deep
and regular. This state is usually of short duration, and the
patients
val,
awaken gradually with no
although
it is
strong stimulus,
about as
if
recollection of the inter-
possible to arouse
when they rub
them by means of a
and look
their sleepy eyes
surprised.
This last form borders closely upon somnambulism, which

occurs during the natural sleep of hysterical patients. The
wander about the room, open the

and
window,
perform many peculiar acts, all of which are
well coordinated.
Sometimes they destroy clothing, hide
patients leave their beds,
objects, or set fire to furniture; later they return to their beds,

and arise the next morning with only a confused recollection
of
what has happened.
may occur during

the daytime, either independently or in connection with a
convulsive attack, a fit of laughing or crying. The patients
then walk about, muttering unintelligibly to themselves,
Similar attacks
are oblivious to the environment, and not the least distractiIt is very difficult to
ble, although able to avoid obstacles.
468
arouse
them from
this state,
even by the application of pow-
erful electrical currents.
This last condition
is
perhaps related to those befogged

which have been described
states with inconsequential speech,
It occurs mostly among prisoners awaiting trial,

who suddenly become dazed, suffer from active hallucinations,
and when questioned give inconsequential answers in spite
by Ganser.
of the fact that they apparently
although with some

exist extensive
difficulty.
comprehend the questions,

At the same time there
and variable areas
of anaesthesia
to
pain.
After a duration of a few days, the symptoms disappear, and

the patients have no memory of the psychosis. In a few
cases a series of these befogged states
may
extend through
several months.
Befogged states with
silly
excitement are encountered in
young patients in whom the clouding of consciousness is

moderate, and does not prevent a recognition of their enPatients usually exhibit a happy, unrestrained
with marked silly behavior. They persometimes
mood,
form all sorts of foolish, wanton pranks, scream, imitate the
The
cries and behavior of animals, and scramble about.
vironment.
real morbidity of this apparently conscious behavior
becomes
evident when, as occasionally happens, it is suddenly terminated by a light convulsive seizure, and then, without
memory
of the foregoing behavior, the patients pass into a
short period of depression.

The memory of the events during the befogged states, as
well as occasionally for events just prior to the onset, is
always
much
ished.
In some cases there are encountered examples of a

which the recollection of previous
disordered,
and sometimes completely abol-
sort of dual personality, in
attacks occurs only during subsequent attacks, being comIt occasionally happens during
pletely lost in the interval.

an attack that some
469
definite period of the patient 's life is
lived over again, similar to what occurs in hypnotic states.

Such alterations in personality arise only under the influence
of autosuggestion.
Nissl finds that twelve per cent, of female insane patients
from various psychoses present some hysterical

symptoms. These occur especially in manic-depressive inBut in
sanity, and also in the early stages of dementia.
suffering
addition to this there occur during the course of hysterical

insanity well-defined mental disturbances, which are a part
of the hysterical personality.
These include sad and anxious
varying duration which appear independently of

any sufficient cause and are accompanied by indefinite
states of
and persecution.
seeing forms and hearing
delusions of self-accusation
may
also speak of
The
patients
threats, but it
these are genuine hallucinations or are really

connected with dreams. Conditions of excitement, arising
is
doubtful
if
as the result of jealousy, spite, and the like, more frequently

appear in the form of passionate outbreaks with violent
abuse, and sometimes a tendency to destroy objects, or even
These usually pass off in a few hours

or at the most a few weeks. Sometimes they recur in con-
to smear their bodies.
nection with the menses.
The course
of the disease is usually protracted,

over
sometimes extending
many years. In women especially the onset of the disease is early, frequently appearing
Course.
at the age of puberty, but it may occur even earlier. The

individual symptoms may show the greatest variation in their
appearance and prominence; indeed, the rapidity and abruptness with which the symptoms change is distinctly characIn a way the disease may be
teristic of hysterical insanity.
regarded as a series of attacks which recur on the basis of
the hysterical personality. These attacks rarely last longer
470
than a few months, and usually do not exist more than

a few days or even hours. But the different depressed,
excited, and befogged states, together with the physical disturbances, may produce a variegated and incongruous picture extending over considerable time. The course of the
disease in children is characterized by less variety of symptoms and a shorter duration, while in males there is a far
more uniform picture with little variation of the individual
symptoms, which may persist unchanged for years.
The diagnosis of hysterical insanity is most
Diagnosis.
The constitutional psychopathic states predifficult in men.
sent a more uniform course, while hysterical befogged states
In
and various physical symptoms are not encountered.
traumatic neurosis there is a far more uniform development.
The differentiation from epilepsy has received sufficient
consideration under that disease.
Finally there may be
some difficulty in differentiating the hysterical befogged
states with inconsequential speech from catatonia, in which
inconsequential speech is frequently encountered, and in
which the areas of analgesia may be mistaken because
of the presence of negativism.
tically
no clouding
The
is
prac-
of consciousness.
differentiation
psychoses in
In catatonia there
of
hysterical
insanity
from those
which individual hysterical symptoms some-
times appear, such as manic-depressive insanity, dementia

prsecox, paresis, etc., must depend wholly upon the presence
of the
symptoms which are
characteristic of those forms of
disease.
The prognosis of hysterical insanity, as rePrognosis.

the
gards
befogged states, is, in general, good; sooner or
with or without treatment, there is an improveor at least a considerable change. The disease in itself
does not progress. The improvement or aggravation of the
later, either
ment
471
symptoms depends very materially upon the
peculiar con-
ditions in
which
the patients find themselves.
At any
rate
The prognosis is less favorable

an increasing tendency to relapses into the
dementia never develops.
where there
varied forms
is
of the disease.
Hysteria in children
is
decidedly
more hopeful, as the symptoms usually disappear with the

development of the child. Occasionally, remarkable cures
by the removal of prominent exciting causes as,
diseases of the sexual organs, injurious environment, and
improper hygiene. In male patients there is a severe form
are effected
of
hysterical
insanity
complaints which
with pronounced hypochondriacal
is resistive
to all
modes
of treatment.
The disease, developing as it does upon a

psychopathic basis, demands prophylaxis in the way of care
of the pregnant mother, and careful supervision of the education and training of psychopathic children. The pregnant
neurotic mother should avoid all forms of excitement and
sources of fear and worry, and conform as closely as possible
to a life of mental equanimity. The child, especially if it
Treatment.
shows a tendency to insomnia, with night terrors or restlessness and evidences of unnatural excitability and precocity,
must be removed from the presence of a hysterical mother,
who
naturally least fitted for

environment, where the child
is
bursts
and
fits
of
has an indelible
between the
its training.
must witness emotional outand

other hysterical symptoms,
temper
effect, particularly in
fifth
Such pernicious
and twelfth
the formative period
years.
Relieved of such surroundings, the main object in the

education should be the development of physical strength
and
and the maintenance of an effective state of

For this purpose, plenty of out-of-door exerwith an abundance of sleep and wholesome diet, must
vigor,
nutrition.
cise,
be prescribed in connection with a discouragement of
all
472
elements of precocity in the mental, moral, and sexual

life, and inculcation of self-control and the nobler senti-
ments.
The same
care
must be continued during the
period of puberty and youth, but should include advice

in relation to sexual matters, sentimental love affairs, and
later relative to the
assumption of the duties of early mar-
ried life, especially sexual relations.

In the treatment of the disease
itself
the element most
essential to success lies in the personality of the physician,

who must inspire the patient with confidence and secure
the
cases, it is
the
family. Except in the lighter

of first importance to isolate the patients and
cooperation
of
establish a suitable routine in the mental
and physical
thereby removing from the environment the disturbwhich have always been a source of annoyance
and have acted as exciting causes. This isolation, although
life,
ing factors
best carried out in a small, well-selected sanitarium, under
the direct supervision of a physician, can be accomplished,

with the aid of an efficient nurse, at the home. At all events
the patient must be given over entirely into the hands of
the physician, who establishes confidence and control, not
by harsh and dogmatic opposition, but by gentle persistence,

in which he must combine firmness and even boldness.
This
accomplished, he
is
in
a position to bring about great im-
provement, and often recovery, by simple remedies. Attention should be directed to any possible organic disturbances
in the stomach, intestines, kidneys, heart, lungs, and sexual
Iron should be prescribed in anemia, and restoraorgans.
tives
employed
in conditions of emaciation, as well as bitter
tonics for anorexia.
On
therapy can be relied

excellent results.
Of the mechanical
the other hand, mechanical
to produce
measures the most important are hydrotherapy,
upon
electricity,
473
massage, exercise, and employment. In the use of hydrotherapy Collins regards the tonic bath the best, in which
the water, at a temperature varying from
fifty-five to sixty
applied under from fifteen to twenty pounds'

from four to five seconds, followed by a Fleury
spray of eighty degrees and similar pressure for one to
two seconds. In the use of the bath hysterogenic zones
degrees,
is
pressure for
must be protected. The reaction should be

passive movements, walking, or gymnastics,
hour following the bath. Where this bath
duce the desired
effect or is
the use of the Scottish spray.
facilitated
for
by
one half-
fails
to pro-
not well borne, he suggests

It is
always desirable, when
possible, to avail oneself of a hydriatic institution for these
The treatment can be accomplished, however,
purposes.
in a house
supplied with water under sufficiently high

pressure by the simple use of a detachable hose and a tube.
This should always be under the direct supervision of the
physician,
who
will find it necessary to
vary the details of
the treatment according to individual cases. When the

bath is not accessible, the drip sheet may be used, the description of which
may
be found under the treatment of acquired
neurasthenia.
In the application of electricity the faradic current
most
service in improving the nutrition
anaesthesia
The
and
and
is
of
in relieving
hypersesthesia.
daily routine of the hysterical patient should be one
and relaxation, including

and
out-of-door
massage, gymnastics,
exercise, combined
with some sport which tends to increase self-reliance.
There are a few cases which require surgical treatment
of activity, alternating with rest
for the alleviation
of organic disturbances in the sexual
organs, especially where the symptoms of the disease seem

to bear a definite relation to the menstruation.
Removal
474
of slightly diseased or even
improvement
in a
few
cases,
normal ovaries has produced

but it is the general verdict of
to-day that this drastic procedure has more often been of

1
detriment than benefit, and should be discarded.
because those susceptible to hypnotic suggestion are apt to be influenced by any

powerful suggestion that happens to be presented. Fur-
Hypnotism
is
of limited value,
thermore, hypnotic experience brings about an undesirable

dependency of the patient upon the physician, which makes
impossible an effective subjugation of their own wills in the
strife with the morbid influences.
The greater the influence
the more easily autosuggestions arise, and the

the
quicker
efficacy of the hypnotic suggestion is nullified
by other and opposing ideas. In mild cases, and especially
exerted,
in children, suggestive therapy is of considerable
importance
overcoming individual hysterical symptoms, such as
in
paralyses, sensory disturbances,
and tremor.
On
the other
hand, simple suggestion is a therapeutic measure of great

value in every case, and often suffices for the complete dis-
appearance of paralyses, contractures, aphonia, etc.

In the treatment of the hysterical attacks, the patient
can often be restored to clear consciousness by a brisk
command, or, if this fails, by a dash of cold water upon the

face, by the electric brush, or pressure over the ovaries
or upon the hysterogenic zones. In very severe cases inhalations of chloroform
1
may be
necessary.
Angelucci, e Pieracini, Rivista sperimentale di freniatria,
XXIII,
290.

B. TRAUMATIC NEUROSIS
475
(Traumatic Hysteria)
Traumatic neurosis
arises as the result of
trauma and
gradual appearance of a prolonged

period of mental depression accompanied by numerous motor
and sensory nervous symptoms. The trauma may occur in
characterized
is
by the
the form of sudden fright, intense anxiety, great misfortune,

or an injury in connection with a fire, railroad accident,
explosion, earthquake, sunstroke, or electrical shock.
Cases of this sort were
recognized and well described

was not until the investigation of
first
by Erichsen in 1886, but it

Oppenheim and Striimpell in 1889 that the disease was
The
clearly differentiated and received its present name.
of
a
such
has
met
with
or
disease
more
recognition
always
less opposition, especially by French writers, and more
recently from Schultze, Hoffman, and Mendel, who maintain
that the disease
matic
is
either hysteria or neurasthenia of trau-
origin.
At present there
no adequate explanation of
the pathology of the disease. Westphal and his school consider that there is an organic basis to be found in changes
Etiology.
is
of the central nervous system.
Charcot regards the disease

as closely related to the hypnotic condition, because the
1
Oppenheim, Die traumatischen Neurosen,
sche
2.
Auflage, 1892
Schultze,
klinischer Vortrage, N. F., 14 (Innere Medicin, No. 6) DeutZeitschr. f. Nervenheilkunde, I, 5. u. 6, 445; Striimpell, Miinch-
Sammlung
ner Medicinische Wochenschrift, 1895, 49 u. 50; Sanger, Die Beurteilung
Nervenerkrankungen nach Unfall, 1896; Fiirstner, Monatsschr.

Unfallheilkunde, 1896, 10; Schuster, Die Untersuchung und Begutachtung bei traumatischen Erkrankungen des Nervensystems, 1899;
der
f.
Sachs und Freund, Die Erkrankungen des Nervensystems nach Unfallen

mit besonderer Beruchsichtigung der Untersuchung und Begutachtung,
1899; Bruns, Die traumatischen Neurosen. Unfallsneurosen, Nothnagels
Handbuch, XII,
1, 4,
1901.
476
disease picture wholly resembles the picture of a firmly

rooted autosuggestion. The psychical origin of the disease
This theory is substantiated
is the generally accepted view.
by the
facts that the neurosis
sometimes appears without
injury, as when it follows fright or slight injury to

other parts of the body than upon the head; and that the
manifestations of the disease are not necessarily limited to
known
the part where the injury occurs, but may be general. In

cases following head injury it is held that delicate pathoExperilogical changes occur in the cortical neurones.
mentation upon test animals, in which definite pathological

lesions in the neurones can be produced by concussion without severe injury, would seem to verify this supposition.
It is doubtful whether the emotional disturbance at the
time of the accident should be regarded as the cause of the

disease, as very frequently weeks and even months elapse
symptoms appear. An important factor,

the
undoubtedly,
psychical influence of membership in
accident insurance societies, of possible indemnities, and of
before the
first
is
suits for
exist,
damages.
At any
rate, in cases
where these factors
the neurosis seems to run a more unfavorable course.
The symptoms regularly worsen

when they are apt to improve
until settlement is reached,
rapidly and often entirely

Another
of
element
disappear.
importance is the defective
constitutional basis, in which alcoholic intemperance plays
a considerable role.
The symptoms develop gradually

Symptomatology.
in the course of a few weeks or months following the shock,
and
and
and an
consist chiefly of despondency with anxious fears
of the
power
of physical
and mental
resistance,
loss
in-
earnest employment.
capacity for any

Patients seem quiet
is
slow,
and they take
and low spirited.

and less interest
less
Apprehension
in the environ-

The
477
becomes unusually uniform

centers
about
and
the accident, to which
mostly
sluggish,
the patients refer over and over and often describe in
"
hard luck," present deplordetail, laying stress upon their
able condition, and hopeless future. Sometimes comHypochondriacal ideas
pulsive ideas and phobias appear.
become very prominent. Patients cannot rid themselves
of thoughts of the accident and fear that they have been
ment.
association of ideas
and
severely injured, because they are not the same, are always
They observe caretired, exhausted, and unable to work.
about their physical condition connected
fully everything
with the injury.

In emotional attitude patients are very irritable, sensitive,
and easily thrown into a state of perplexity or confusion,
are unable to express themselves with perfect coherence,
their thoughts and actions are conhindered
by feelings of inward oppression and
stantly
anxiety. This anxiety may lead to passionate outbursts
and are conscious that
and even
Memory, in spite of complaints

to the contrary, is good, if one makes allowance for the lack
of interest in the environment and the faulty attention.
When
suicidal attempts.
agitated, the patients
simple problems.
may
not be able to solve even
Their capacity for work
is
greatly
ham-
pered by hypochondriacal notions and numerous nervous

complaints. Whenever they attempt to do something,
headache, palpitation of the heart, excessive perspiration,
etc.,
develop.
The mental symptoms usually do not

casionally befogged states or
ment appears.
If
due to a cerebral
Ocprogress.
excite-
an acute hallucinatory
mental impairment develops,
it is
usually
lesion.
Physical Symptoms.
Sleep is disturbed by anxious
dreams, the appetite is poor, and nutrition becomes impaired.
478
Patients complain of various sensations in the head and

back, especially parsesthesias and pains in parts of the body
injured at the time of the accident. Pain, which is usually
the most prominent symptom, is persistent and troublesome
and may lead
In addi-
to immobility of the parts involved.
tion, patients complain of ringing in the ears, loss of strength,

palpitation of the heart, difficulty of urination, and occasion-
obstinate vomiting.
Some cases present objective
symptoms, such as areas of analgesia and of hypersesthesia,
constriction of the field of vision, difficulty of hearing,
ally
increased tendon reflexes, paralyses, slowness

tainty of movement, and disturbance of gait
Tremor, especially of the
and uncerand speech.
fibrillary type, is often present,
being either general in character or involving only muscles

of the paralyzed part.
Paralysis may occur in the form of
hemiplegia or paraplegia, but the facial and hypoglossal

nerves are seldom included. The paralysis almost always
occurs on the
same
side as the accident }
and
is
frequently
accompanied by contractures. There is often an acceleration of pulse and sometimes of respiration following emotional
disturbance, pressure on the painful points, or muscular
Occasionally, also, vertigo or even epileptiform
Localized
attacks may be produced in the same way.
exertion.
muscular spasms
and convulsions are common.
Vaso-
motor disturbances occur, as localized blushing, cyanosis,

and dermography. Sensory disturbances, both subjective
and objective, of which hypersesthesia is most prominent,
usually involve the injured side of the body.
All of the motor and sensory nervous disturbances are to be
distinguished from those accompanying organic brain
and
cord lesions by their location, their broad extent, changing

condition, and the fact that they worsen under the influence
of emotional
and physical disturbances.
Friedmann adds
479
that these patients have little power of resistance to alcohol,

galvanization of the head, and compression of the carotids.
The
terical insanity is distinguished
often very difficult.

Hysthe
lack
of
by
uniformity of
in a given case;
the hysterical patients pre-
Diagnosis.
the
symptoms
sent a variegated
diagnosis
is
and transitory
alteration of
symptoms,
capriciousness, pronounced changes of disposition, desire

for undertaking something new, and great pliancy.
Furtherdoes
not
present befogged states.
more, traumatic neurosis
The
constitutional psychopathic states are differentiated by

the fact that the onset is not sudden, does not depend upon
an injury, and has a less favorable course.
Simulation should always be taken into consideration.

Unfortunately the various objective symptoms, constricted
field
of
vision,
acceleration
of
pulse,
increased
tendon
reflexes, and absence of galvanic excitability, are of little

value in establishing a positive knowledge of the existence of
a mental disorder. Deception cannot be unmasked by the
presence or absence of any one
symptom
or group of
symp-
toms, but must depend upon the conformity of the whole

clinical picture to one of the known disease-symptom groups.
Recently psychological tests have been successfully employed

to prove the mental symptoms; as, for example, psychological
tests of the power of apperception, test of diminution of the
ability to figure, the susceptibility to training,
fatigue.
Thus
it
and
especially
has been shown that in traumatic neurosis
marked loss in the capacity for work

and a very great increase in the susceptibility to fatigue.
The lighter cases of traumatic neurosis apPrognosis.
there should be a
pearing soon after the accident may improve rapidly, but

even some of these run a long course and have an unfavorable outcome.
Yet, after a duration of many months or

even a few years, the disease may terminate in recovery or
480
great improvement. The prognosis is less favorable in

the presence of pronounced focal symptoms or general
arteriosclerosis.
Treatment.
The
first
indication
is
to dispel as far as
ideas of litigation. Next to this, employment

possible
It often happens that the symptoms
is of the greatest value.
of the disease disappear rapidly as soon as litigation is
all
settled or patients are compelled to go to work again.

residence in an institution with the opportunity for employ-
ment and
distraction frequently serves to bring about great

improvement or recovery. In all cases hydrotherapy, massage, exercise, electricity,
and hypnotic suggestion, as well
as dietetic regimen, are of value.

C.
The dread
rotic cases in
neurosis
The
comprises a small group of neusuffer from a more or less
which the patients
constant feeling of
entire
DREAD NEUROSIS
anxious suspense
which dominates
the
life.
conditions about which the
anxiety develop are

that
take
usually processes
place without conscious
normally
interference, such as walking, standing, drinking, writing,
etc.
The anxiety almost always appears for the first time
immediately following some real but trifling condition, such

as an experience during which the eyes have been subjected
fatigue or a dazzling light, moderate overexertion,
fatigue after a long walk, etc. Anxiety about sleep may
to
periods of emotional stress. Frequently some

physical disease initiates some of the symptoms: a feeling
follow
weakness follows a mild rheumatic attack, or pain in the

In addition to feelings of anxiety there
leg follows a fall.
of
regularly develop uncomfortable and even painful sensations,

as well as a sort of paralytic weakness which interferes with

the movements.
The
pany the process
481
painful sensations, especially, accom-
of apprehension,
while
weakness appears during exertion of the
the
muscular
though both
occur together. The anxiety and the accompanying sensations usually occur first in connection with some simple
will,
such as eating certain kinds of food, reading in bright

But they gradually
sunlight, or sleeping in a certain place.
act,
become more extensive and may

lar acts
wholly impossible.
render some particuIn one patient insomnia first

finally
developed whenever she anticipated doing something unusual the next day, such as going to the city, but later the
most trifling affairs would cause it to appear.
The
clinical
is
picture
variegated; while patients are

then there is a feeling of heat,
reading, letters will disappear,
a sensation of tension, photophobia, and pains that streak

across the forehead, which ultimately compel them to cease
reading altogether. Similar disturbances develop in connection with hearing. In writing the fingers soon stiffen,
or there is great weakness. Swallowing can be rendered
by the appearance of a cramp in the throat. Walking is hindered by weakness in the legs, pains, etc. Sleep
may be impaired by an increasing restlessness, twitching of
the limbs, and palpitation. Some cases of psychical impodifficult
tency belong here.

Patients mistake the true origin of the disorder and begin
to refer it to real diseases of the eyes, ears, muscles, and nerves.
This causes them
greater anxiety, and undermines

Attention is directed more and more
still
their self-confidence.
to these supposed physical disorders,
and thus there de-
velops a vicious circle, each factor adding fuel to the other

and making it impossible for the patients to free themselves.
Increasing sensitiveness of the eyes causes the patients to

systematically avoid light, therefore they do not venture out
2i
482
Pain and weakness,

which interfere with walking and standing, cause the patients
to gradually limit their movements and ultimately to remain
In this state both active and passive
in bed altogether.
save at twilight or on cloudy days.
movements may produce excruciating

movements of the head are singularly
Speech and
pain.
free.
Furthermore,
the disorder ordinarily does not extend into other fields,

but confines itself to the particular process which was
originally involved, as, for instance, to sight or to walking.
Consciousness remains clear patients are oriented, orderly,

;
and do not exhibit emotional
deterioration.
They com-
placently endure the severe suffering which they regard

as purely physical. Hysterical symptoms are never a part
of the disease picture.
Course.
The course
of the disease is usually protracted,
though there are frequent remissions. Efforts upon the

part of the patients to overcome their symptoms only aggravate the
condition.
various
Strenuous
mechanical
efforts
to
relieve
and medicinal
the
devices
patients by
usually effect only a transitory improvement. On the other
hand, many of the patients get well of their own accord.
There is some question as to the clinical
Diagnosis.
position of the dread neurosis; indeed, the lighter forms
have often been considered as cases of nervousness or
neurasthenia,
while Janet describes
many such
cases under
psychasthenia.
Against the former view may be cited the fact that the
patients need not at any time exhibit any other nervous
symptoms, while there is at no time any evidence of nervous exhaustion. Although the symptoms may originate
in some physical ailment, they do not disappear with the
recovery from that condition and restoration of strength.
The
differentiation of hysterical insanity depends
upon the
483
presence of the unconscious influencing of the physical

processes through emotional excitation, while in the dread
alone the condition of weakness and instability
which deprives the patients of their ability to withstand
neurosis
it is
In hysteria the symptoms

frequently alternate from one field to another, but in the
dread neurosis the symptoms are uniform and progressive.
the supposed physical
affliction.
The phobias are distinguished from this disease by the

that the fears are more general in character, while
in this disease there is some definite personal experience
fact
which forms the starting-point. In the phobias the fears

frequently change in several different directions, but in the
dread neurosis fear is uniform, always hypochondriacal,
and has to do only with the patients' own bodies. Furthermore, in the phobias there are real states of anxiety which
embarrass the patients or force them to secure protective
measures, but in this disease the patients are not conscious
which appear to them as
of the origin of their difficulties,
real pain, actual weakness, or genuine ataxia.
Treatment.
patients recover of themselves, without any treatment. In some way or other, frequently
through the influence of some one whom they trust, they
Many
regain self-confidence and with it the strength to conquer

the disease.
On the other hand there are many cases in
which
failure at the first trial destroys all
Patients at
hope of recovery.
seem to react well to new methods of treatreality from the very beginning they are apt
first
ment, but in
to cherish a vague fear that they cannot recover.
Simple
hypnotic treatment often effects a rapid and permanent
recovery. Cases of even ten years' standing have been restored in this way. This form of treatment, however, is
often difficult, and demands that one should thoroughly
understand the technique, in order to gain the confidence of
484
the patient, without which success is impossible. In severe

cases it is often necessary to begin by giving only quieting
suggestions, because premature suggestions as to the cure
might prove disastrous. This method rarely fails. In case
it
does, one
is
not as effective.
suggestion, but its influence

in
this, there is no hope for cure.
Failing
may employ waking
XIII.
CONSTITUTIONAL PYSCHOPATHIC STATES

(Insanity of Degeneracy)
THE fundamental symptom
in
the constitutional psymorbid elaboration of
chopathic states is the continuous
normal stimuli as manifested in a morbid misdirection of

thought, feeling, and will throughout life. These states
develop on a morbid constitutional basis. The commonest
type of psychopathic degeneracy is characterized by those
little imperfections of the individual constitution which
we
These symptoms
ordinarily designate as nervousness.
form the groundwork upon which the more marked forms
of the insanity of degeneracy develop.
These various forms
of the insanity of degeneracy are hard to group, because
there are so many combinations and border-line states. In
the present state of our knowledge the best arrangement
seems to be constitutional despondency, constitutional
and
ment, compulsive insanity, impulsive insanity,

sexual instincts.
excite-
contrary
A. NERVOUSNESS 1
Nervousness comprises several congenital morbid mental

which are characterized in general by an inability to
states
1
Saury, Etude clinique sur la
folie he*re"ditaire
Nervositat und neurasthenische Zustande,

la Tourette, Les e*tats neurasthe*niques, 1898
psychasthe*nie, 2. Bande, 1903.
485
v.
Krafft-Ebing,
Auflage, 1900; Gilles de
Janet, Les obsessions et la
2.
;
1886;
Binswanger, Die
(les de*ge*ne"res),
Koch, Die psychopathischen Minderwertigkeiten, 1893

Pathologic und Therapie der Neurasthenic, 1896;
486
withstand the misfortunes of life, together with a lack of symmetry in the development of the entire psychical personality.
Intellectual
endowment usually
is
not equal to the average,
although occasionally it may be excellent. Some particular

faculty may be unusually well developed; as, for instance, the
sense of form, of color, or memory for numbers. Some
patients may be able to perceive keenly, but yet lack insight into character, or may possess profound knowledge
without any practical bent. Some patients are remarkably
precocious.
Increased susceptibility to fatigue
a prominent symptom.
Hence patients tire quickly and have little endurance. Occasionally they learn with difficulty and quickly forget what
they have learned. Attention shows an increased distractiis
Patients are very sensitive to interruption, and are

easily distracted from their customary ideas and plans by
anything new. These symptoms give rise to flightiness and
bility.
An unusual activity of the imagination

often present. Ideas possess a great sensory vividness and
are easily united.
Consequently there develops a strong
superficiality.
is
tendency to revery, which
is
also favored
by the
distracti-
bility of the attention.
While egotism usually prevails, on the other hand, selfdepreciation and a lack of self-confidence may be present.
Most patients lack the sense of reality. To them the daily

occurrences of the immediate environment seem distant;
"
"
indeed, things do not conthey have a
far-away feeling
cern them any more than if they lived in another world.
;
Deceitfulness
is
also a
from the tendency

products of their
own
are easily falsified
common symptom,
of patients to
arising in part
themselves
with the
busy
imagination. Superficial recollections

by the addition of fictitious facts, even
CONSTITUTIONAL PSYCHOPATHIC STATES
487
without the patients being conscious of it. Furthermore,

the emotional states exert a great influence over the ideas;
hopes and fears guide the thoughts, while vivid impressions

as well as accidental ideas dominate intuition and recollections.
In the emotional
field
there
is
a tendency to asymmetrical
development. Great sensitiveness, eagerness, and excessive

enthusiasm may predominate, while the more natural feelIn connection with an artistic sense of
ings are arrested.
appreciation
obtuseness.
there
may
be
lack of
Unnatural affections arise;
tact or
for
a moral
instance,
fanatic affection for one of the animals, an idolatrous adoration of some person, also numerous idiosyncrasies, or a
senseless abhorrence or fear of certain persons, objects, or
There are many striking peculiarities

morbid tender-heartedness,
of the emotional attitude,
disease
symptoms.
extravagances, or persistent timidity and cowardice. Rapid

and sudden changes of the emotional attitude are frequent
exuberant happiness suddenly changes to seclusiveness or
:
outbursts of fury; patients become excessively angry and

just as quickly placid.
In accord with the feeling of egoism, the patients attend

chiefly to their own thoughts and busy themselves with
own welfare. Thus they observe in a most painstaking

manner the minor physical changes, which then rapidly
multiply and cause apprehension. Constant thought of self
and superficiality of the feelings gradually leads to selfishtheir
ness.
Patients are cold, unapproachable, associate with no
one, and are most inconsiderate of nearest relatives. They

degrade themselves in numerous ways in an effort to arouse
special recognition and sympathy.
The actions of the patients show constant constraint.
Voluntary impulses do not arise from established principles,
488
but from momentary feelings and impulses, as well as through

accidental impressions. Fears and passionate impulses
harmonious development and release of
interfere with a
Hence patients are never able to follow

to
its
conclusion, as is clearly indicated in their
anything
and weak attempts at suicide, showing
foolish
occasional
voluntary action.
an
inability to transform their desperate feelings into reso-
lute acts.
The
do
patients themselves usually feel their inability to

If
at the outset
satisfactory and uniform work.
they seek to become masters of their own imperfections

by means of a strong exertion of the will, they gradually
lose ground.
ness
constant struggle regularly leads to weari-
and enervation.
from any
Impulsive
patients gradually withdraw

serious activity and let things go as they will.
acts,
Many
foolish
journeys,
precipitate
betrothals,
changes of location and profession, and attempts at suicide

are constantly occurring.
Impulsiveness becomes more and more
prominent, and
certain habits of will often develop which are exceedingly

difficult to break up.
Patients must conduct their business
always in a certain way, and at once become embarrassed and

ill at ease as soon as a
change takes place. They are apt to
fall an easy prey to the misuse of drugs, become drunkards,
drink strong tea and coffee, and are frequently given to
excessive dosing with quack remedies.
The
sexual
life
is
usually an important factor.
impulses develop early and
Sexual
an abnormal degree, often

to
masturbation, which usually becomes deeply
leading
rooted and is often practised in addition to regular sexual
intercourse.
Occasionally the sexual impulse becomes the
central point about which the entire life revolves, producing
the picture of sexual neurasthenia. The sexual desire may
to
489
be accompanied by an intense feeling of discomfort, even

incapacitating the individual, and disappears only with
On
the other hand, intense feelings of anxiety

the
sexual act, frustrating its accomplishmay accompany
ment and leading to mental impotence. Increased sexual
gratification.
excitement induces reckless masturbation, resulting in a

constant overexcitation, premature ejaculation, and spermatorrhoea, associated with hypochondriacal fears. Ultimately all kinds of morbid sensations and ideas may develop
around
this central point.
The weakened power

the most varied ways.
of resistance
may
manifest
itself in
Nervous individuals often develop
a high temperature upon slight provocation, easily become

delirious, or faint
Furthermore, there
during excitement.
is great susceptibility to alcohol, as well as to tea and coffee,

rapid collapse under stress, inability to withstand hunger or
thirst,
and a great dependency upon weather and tempera-
ture.
There
is
also a tendency to pressure in the head,
false sensations of all kinds,
headache,
bility of the heart.
The taking
of food
and increased
is
irrita-
also involved in the
appetite alternates with

loss of appetite, nervous dyspepsia often develops, as well
as sensations of pressure or fulness in the stomach, etc.
general
Sleep
is
disturbance;
voracious
frequently disturbed.
In some cases there
is
an
extraordinary demand for sleep, so that even after eight or

nine hours of sleep the patients can hardly be aroused.
Many
patients feel a great weariness upon awakening,

is disturbed by restless dreams.
and
their sleep
Degeneracy is often apparent in various physical defects;

such as, a lack of development of the body beyond a puerile
stage, either a very youthful or a senile countenance, localized or general cessation of development of the brain and
skull,
abnormal position of the
teeth,
malformation of the
490
and hands.
ears, palate, sexual organs,
Occasionally there
are residuals of an old cerebral disease.
Since nervousness according to our conception

a congenital morbid state, one cannot speak of the disease
Course.
is
as having a characteristic course. Usually the morbid constitution first shows itself in childhood by great restlessness,
by
irritability, sensitiveness to injuries,
minor nervous
dis-
turbances, convulsions, enuresis, night horrors, stuttering,

etc.
Later, difficulties are encountered in teaching the
on the one hand, great irritability, passion, and

rebelliousness, and on the other, susceptibility to seduction
children;
and sexual
sense
of
influences, fickleness, anxiety, irresolution, great
fatigue,
and
distractibility.
Occasionally there
develops a tendency to lying, thieving, and truancy. Many

of these symptoms may improve under favorable circumstances.
There
is
often observed an increase of the morbid
symptoms during the period
of development, in spite of all

measures.
This may be due in part to
corrective
possible
the unfavorable influence of the general physical and mental
evolution at this period,
and
in part to the gradually in-
creasing demands of life. Furthermore, persistent masturbation, alcoholic excesses, exhausting diseases, pregnancy in
women, and, under some conditions, intense emotional
excitement are pernicious influences which regularly aid in

bringing the disease to its full development.
Nervousness is often mistaken for neuDiagnosis.
rasthenia.
In neurasthenia the symptoms of fatigue only
are present, except in marked conditions, while in nervousThe more marked

ness there are signs of degeneracy.
these signs are in a given disease picture, the more cautious
one should be in considering as a cause for the condition

an alleged nervous exhaustion. The symptoms of simple
nervous exhaustion rapidly
mend under
the influence of rest,
491
but the symptoms of nervousness, when once aroused, run

an independent and, under certain conditions, a progressive
course, even
if
the immediate exciting factors have
In addition to
been
nervousness
develops at
any time from youth up without any appreciable external
cause and assumes varied forms, while nervous exhaustion
corrected.
this,
never attacks healthy nervous systems without some powerful injury.
Treatment.
Prophylaxis is of greatest importance.

Defective persons should be dissuaded from marrying each
Of the particular injurious influences to be combated, alcoholism is the most prominent. During childhood patients need special attention paid to their education
and training, which should be proportionately divided between the body and the brain. The mental development
other.
should be retarded
if
there are
any evidences of precocity.

on the amount of sleep
Particular stress should be laid
and the patients should be permitted all the sleep

they desire. At the time of the awakening of the sexual
impulses, the children must be carefully watched and in-
received,
structed.
Very often
it is
best that the childhood should be
passed in the country, in order to give the body as much

opportunity as possible to develop, to eliminate confinement
and
to avoid the pernicious influences of bad

If the disorder is very pronounced,
associations in cities.
in school,
manual training under the supervision of a physician is

desirable.
Psychopathic children, on account of their faulty
The
constitution, do not tolerate routine training well.
In
training should be adapted to personal peculiarities.
the choice of an occupation one must take into consideration
Uncongenial and annoying employment

makes the symptoms worse, while simple, regular, and
uniform work often does much good. Patients should
their imperfections.
492
Alcohol in any form must be forbidden.

Furthermore, morphin and hypnotics can be prescribed only
with the greatest care.
avoid
all
excesses.
The individual symptoms themselves are best combated

by means of an intelligent training under medical supervision, regulation of the entire
life,
with due regard to a pro-
portionate amount of work and recreation, sufficient sleep

and nourishment. Long-drawn-out " cures " are usually
unsatisfactory, especially in institutions, as the complaints
and hypochondriacal fears tend to increase under' such con-
and should be resorted
ditions,
On
reasons.
to only for very definite

the other hand, the necessity of meeting some
regular obligations serves as an important remedy. If

relaxation is necessary, it is usually best accomplished by a
short journey or a sojourn at the sea or in the mountains.
These patients, in general, demand frequent but short pe-
Where there is despondency, diversion

of social intercourse, distractions,
means
by
and amusements.
riods of relaxation.
is
best obtained
artistic efforts,
B.
CONSTITUTIONAL DESPONDENCY
Constitutional despondency -is characterized

sistent feeling of sadness which pervades all of
by a
life's
per-
expe-
riences.
Intellect
shows no striking disturbances.
Some
are well endowed, while others from youth are
backward
tigue
ing
is
mental development.
greatly increased
up a
quickly,
in
piece of
The
patients
somewhat
susceptibility to fa-
while patients are capable of tak-
work with
demand frequent
and skill, they tire

and are wholly unfit for
intelligence
rests,
steady application to mental or physical work, because of

resulting headache, insomnia, or general malaise.
Under

stress of circumstances
493
they are often able to temporarily
overcome these hindrances.
Distractibility of the attention
greatly increased, so that even the most trifling affairs

in the surroundings may greatly interfere with systemHence their work is uncertain, and sometimes
atic work.
is
has to be done over several times.
There
a tendency
Consciousness re-
to display hypochondriacal complaints.
mains
is
and
thought is coherent. Patients

often appreciate their unfortunate condition.
In emotional attitude they are oppressed and sorrowful.
They may have always been especially susceptible to the
unclouded,
cares, sorrows,
and misfortunes
of
life.
Present pleasure
is
always clouded by past sorrow or troubled fears for the
Many patients to all external appearances seem

normal and only disclose their sadness to their families or
the physician. Under the influence of some excitement
they may temporarily become happy and cheerful, but soon
future.
Any undertaking dismays

relapse again into their misery.
or
no
and
little
take
they
pleasure in any occupation.
them,
They lack self-confidence, are easily discouraged, feel that
they are of little use in the world, are nervous, sick, and fear
the outbreak of some awful disease, especially insanity.
Some
are always troubled with the feeling that they have

done something wrong, or that some ill will befall them.
They are especially apt to worry about

The sexual impulses are usually awakened
their sexual
early
life.
and lead to
excesses, especially masturbation, the consequences of which

the patients always paint in the darkest colors. Sometimes
the patients are sentimental.
Conduct
greatly influenced. If anxiety predominates,

patients shrink from every obligation, dread the most remote
possibilities, and avoid everything to which they are unac-
customed.
is
Many
patients are deliberate, find
it
difficult
494
to arrive at a decision, and tend to exhibit great precision

and punctuality in little things. They use an endless amount
of time without accomplishing anything.
They
stick
so
tenaciously to every task that they are gradually reduced

to a smaller and smaller sphere of activity. They excuse
themselves for not going out into society because they

have not time, and they cannot travel because it is too diffi-
Ultimately their whole activity may be

confined to keeping the house clean and preparing meals on
time.
Some patients are constantly thinking of death and
are always making preparations to die. Though they may
cult to get ready.
not seem in earnest about

that they
make attempts
it,
yet
it
not infrequently happens
Very often
at suicide.
all sorts
of nervous complaints interfere with their ability to work,

such as pressure and pain in the head and peculiar sensations in all parts of the body.
Occasionally some peculiar
motor symptoms are observed, as grimacing, choreiform

movements, clucking with the tongue, snuffling, and twitch"
"
These tics accompany all the different
ing of muscles.
Sleep is usually much disturbed.
course of the disease is prolonged, with
forms of degeneracy.
Course.
The
irregular remissions; but within certain limits
runs a very
The condition regularly
it
uniform course, lasting for years.

becomes worse after emotional shocks and physical disease
and even without any apparent cause. Gradually the
patients may become better, but it rarely happens that they

are entirely free from symptoms. At first remissions may
occur, but later there
persist, until finally
with
little
variation.
a tendency for the symptoms to

there is a continuous morbid condition
is
Even during the
remissions, patients
always display some evidence of mental peculiarities: they

are quiet, dull, shy, or unfriendly.
Treatment.
The
patients can be
made very comfortable
495
by a well-regulated life in a favorable environment/ but

family strife and increased responsibilities always diminish
chances of recovery. On the other hand, absolute freedom
tends to make the patients worse. Suitable employment is
must be so adjusted as to gradually increase

the responsibility and the exercise of strength. While the
necessary, which
therapeutic agencies, as massage, hydrotherapy,

electricity, etc., are of importance, their chief value lies in the
special
psychical influence which can be exerted through

creating
new energy
for
in
work and
fidence.
Hypnotic suggestion
insomnia and pain.
0.
them
is
in establishing self-conoften helpful in cases with
CONSTITUTIONAL EXCITEMENT
Constitutional excitement constitutes a small group of

cases characterized by permanent moderate psychomotor
excitement.
The intellect of these patients is fairly good, but they

are hindered in acquiring full and complete knowledge,
because they are not persistent at their studies and are
extremely distractible.
Perception is usually unimpaired,
knowledge of life and the world is superficial, mental elaboration of experiences
experiences
falsified
less,
is
with
fleeting,
many
and judgment
In emotional
less.
is
hazy and scanty, and memory of early
is
and often colored and

Thought is flighty and aim-
one-sided,
additions.
hasty and superficial.
happy and thoughta

They possess marked feeling of egotism and are boastattitude the patients are
own capabilities and accomplishments. They

do not appreciate their imperfections. Toward others they
are apt to be lofty, irritable, dogmatic, and unsympathetic.
ful of their
They usually
deride, torment,
and abuse those who do not
496
agree with them, but on the other hand, they do not become
mortified when reproached and insulted. They devote much
time to amusements and diversions of
all
kinds and are given
making fun of themselves and others and playing tricks.

They readily adapt themselves to new conditions and are
to
always longing for a change. Occasionally transitory, anxious, or despondent emotional conditions develop.
In actions and manner the patients are
stable.
are
They
easily
approachable,
restless
and un-
often loquacious,
but wholly untrustworthy and vacillating in their judgment.

Consequently their lives are one series of thoughtless,
venturesome, and often foolish acts. Even in school they are
rebellious
and
disorderly.
They
react badly under military
discipline, neglect the rules of cleanliness and order, misuse
furloughs, neglect their duties, and frequently need to be

punished. Sexual impulses often develop early and lead to ex-
They frequently become addicted to the use of alcoThey are constantly moving and changing employment
without sufficient reason, always beginning something new
cesses.
hol.
and devising great schemes which are soon forgotten.

They often make propositions which they cannot live up to,
assume lofty titles, and secure recognition by boasting.
The lack of plan in their undertakings is most characteristic
and clearly shows how little their pressure of activity is
held in check
their resources,
by careful reasoning. They soon exhaust

and then they begin to borrow, to cheat, and
In trying to maintain their credit they always

refer to some great "deal" which they are about to put
through, a position which awaits them, their intimacy with
to swindle.
prominent individuals, betrothals to heiresses, etc. When

thwarted they maintain that they are in the right, that they
had no idea of fraud, and that they will shortly be in a

position to meet all of their obligations. Following punish-
497
ment, they again return to their old tricks, until finally

the morbid character of their conduct is recognized.
The similarity of constitutional excitement
Diagnosis.
to hypomania is very striking. The differentiation depends
upon the fact that in constitutional excitement the excite-
ment
is less
but
is
of
constitutional
a fixed personal peculiarity. Nevertheless some cases

excitement develop transitory exacer-
bations
pronounced, does not recur in definite attacks,
and even
delirious states, while others
cal vacillations together with irritability
and
show
periodi-
rebelliousness,
and, finally, occasional anxious states with indefinite delusions of persecution. These cases are only another indication
we
have to do with a permanent disorder of the

mental equilibrium which constitutes the first step toward
that
really
true manic excitement.
These cases also remind one of those
cases of manic-depressive insanity, hi the lucid intervals of

which moderate excitement of the same character occurs.
Some
refer to
both conditions as a chronic or constitutional
mania.
The mildest forms
of constitutional excitement
approach
very closely to certain defective constitutions which are

ordinarily regarded as belonging within the realm of normal
man. These are usually encountered in

whose members have suffered from forms
sive insanity.
They
versatility,
some
of
of manic-depres-
comprise certain brilliant but never-
theless one-sided personalities
their
families
enthusiasm,
which charm one by

their artistic
abilities,
their
and
happy, sunny dispositions, but who at the same time astonish

one by their restlessness, volubility, lack of steadiness and
persistency in employment,
and
their tendency to evolve
numerous schemes.
Occasionally they exhibit periods of

unreasonable despondency, which sometimes follow over-
work and disappointments.

tx
The frequent
history of de-
498
spondency ending in suicides occurring in the parents,

brothers, sisters, and their children, or of genuine manicleads to a strong presumption that
sanguine temperaments of this sort are nothing more than
initial psychopathic stages of manic excitement.
depressive insanity,
The treatment
Treatment.
is
difficult
because
the
patients lack insight into their condition and, therefore,

will not submit to medical advice.
In many cases it is
necessary to occasionally restrict the freedom of the patients,

because otherwise they get into serious difficulties.
By
means
of firm
and
friendly guidance
cient protection against sexual
and
and
especially
by
suffi-
alcoholic excesses these
patients can sometimes be made to follow some useful

employment, but in spite of all advice and regulation they
always remain
care
fickle
and anxiety to
D.
and
unreliable
and a source
of constant
their friends.
COMPULSIVE INSANITY
In this psychopathic state compulsive ideas and compulsive

fears are the
The
predominant symptoms.
not only undisturbed, but
intellect is
ally good.
ing of
may
be unusu-
Patients exhibit throughout a pronounced feelillness and frequently a clear insight into
mental
the morbidity of the individual symptoms. Many present

symptoms of constitutional despondency before the com-
and
Moreover, the initial symptoms usually develop during conditions of despondency.

The compulsive symptoms may be grouped under three
pulsive ideas
heads
fears appear.
the tormenting ideas (manies mentales), the phobias,
and the impulsions.

Tormenting Ideas. The feeling of anxious uneasiness
which accompanies all of these symptoms produces a seIt is not improbable
ries of psychogenic disturbances.
499
that the sensation of strangeness referred to in nervousness

is nothing more than a peculiar expression of a concealed anx-
which impairs the patients' sensations and influences

the perception of the outer world. Consequently the feeling frequently arises in the patients that they cannot comiety,
prehend anything more, cannot follow conversation, or cannot get the sense of that which is read. Thus there develops
an endless repetition of the same tormenting thoughts which
disturb the patients all the more if they attempt to dispel
them. Associated with these feelings there develop peculiar
physical sensations all over the body; such as, weariness,
palpitation of the heart, blushing, blanching, nausea, and
sometimes even vomiting. Furthermore, the anxiety leads
to a mixture of voluntary and involuntary impulses, which
are thus altered in various ways. Finally the patients evolve
methods of self-relief.
The simplest form of compulsive insanity is represented
by the simple compulsive ideas which force themselves upon
the patients against their will, and in this way influence the
peculiar
freedom of thought.
Sometimes the compulsive idea
is
very simple or at least not irritating. It is only the frequent

Sometimes
repetition of the idea that causes annoyance.
accompanied by an hallucinatory picture of great

vividness. Odors and melodies may similarly haunt patients.
the idea
is
when they
are disgusting
or create horror. Many patients complain because they are
compelled to contemplate the sexual organs of those about
Such ideas are
them.
especially annoying
Others when at stool have to dwell upon
all sorts of
disgusting scenes.
In another group of cases there
is
a compulsion to ponder
over certain definite things; for example, the names of per1

sons (onomatomania), and particularly difficult names.
1
Magnan, Psychiatrische Vorlesungen, 1893.
500
Unable to
recollect
name
casually heard or seen, the
patients immediately strain every nerve to recall
about
it all
day long,
and the tension cannot
lie
it,
think
awake nights
trying to recall it,

be relieved until they succeed.
Some
patients feel compelled to inquire the names of people

whom they meet on the street; others feel that they must
form a
definite picture of the face, form, or color of the hair
Other patients dwell on figures (arithmoare

and
compelled to busy themselves with the
mania),
number of the house, the street, the number of guests about
the table, the number of forks, knives, and glasses, the numof strangers.
ber of designs in the carpet or wall paper.

Compulsive ideas sometimes take the form of questions;
"How was the universe created?"
as, "Who is God?"
etc.
Sometimes these questions
refer
to objects in the
"
surroundings, when such questions arise as,

Why does
" "
that chair stand thus and not so ?
does
it have
Why
" "
and
no
four legs
more or less ?
Why is that house painted
"
and
?
not
brown
This
has
been been called Grubelgreen
a passion for pondering over things.
sucht
Some
patients are in doubt as to the accuracy of their

memory; still others have the feeling that they may not
recognize their acquaintances when they meet them again,

or will not remember what they last said to them.
Some-
times these feelings of uncertainty seem like ideas of selfPatients feel that they have neglected some-
accusation.
thing or have not done something right. When urinating

or defecating, the patients may have the feeling that the dis-
charge is incomplete, and therefore they must make further efforts. After every conversation the idea arises that
they may not have made themselves clearly understood.

After leaving a friend, they sit down and write a letter in
order to be sure that they are understood, but the letter is

barely off before they are in doubt as to whether they
themselves clear in it. These patients weigh every
501
made
word
before they express themselves, trying to avoid false interSome patients always have the idea that they
pretations.
have taken some other person's hat, umbrella, or overcoat.

In counting money they carefully scrutinize every coin
might have made a mistake, or that they

had not paid out enough, and hence would be accused of
for fear that they
Many patients accuse themselves- of not having

confessed everything at the confessional or of not being
"
contrite of heart."
fraud.
Very often the patients have the fear of destroying or

misplacing something of value. In many cases their fears
that they are guilty of crime, of
homicide, have committed a theft, or have poisoned a relaIn the lighter forms these doubts exist only in one
tive.
are quite
silly;
they
feel
in t{ie severer forms they influence all the

"
actions of the patients.
Perhaps it would have been bet"
if
I have harmed
I had not drunk that glass of water," or
ter
"
Had I not gone
myself by taking that piece of cake."
field of activity;
out of doors, it would have been better; that accident would

not have happened or that fire would not have broken out."
It is actually impossible for these patients to
remain at rest
because of the uncertainty as to whether they have closed a

door or have sealed a letter that they have mailed. Consequently they manifest an ever increasing painstaking in
all the little details of daily life.
They are always turning
back to see if they have locked the door, or tearing open
they have enclosed the right one. It is often

characteristic of these patients to make use of some par-
letters to see
if
movement which they have discovered,

High Jinks," or to cough, upon which all doubt
ticular phrase or
such as
"
This whole group of cases has been desigdispelled.

nated by Legrand du Saulle as "folie du doute."
is
502
There
is
also a condition called erythrophobia, in
When any
patients fear blushing.
which
one enters the room or
name
is spoken, they immediately blush, which causes

for fear that they may be thought guilty
discomfort
great
It may even create so much annoyance
of some misdeed.
their
that they are compelled to give up business. There is also

the fear of wearing new clothing because of the newness and
accompanying physical discomforts.
The strongest feelings are connected with the welfare of

the body. Many patients perceive all kinds of sensations
When dropping
in their bodies which cause them anxiety.
the body seems to increase to an enormous size.
patients have the uncomfortable feeling that the urine
off to sleep,
Some
They fear that they are going to lose their

minds or become paralyzed. Others have the idea they will
Some fear a sunstroke, and in consesuffer from syphilis.
is trickling.
quence are taking all possible precautions still others have

the foolish fear of snakes, of cats, or that a beetle will crawl
Some avoid going into the street for fear
into their ears.
;
that a stone or a
The
man may
fall
upon them from a
sexual relations also offer a fruitful field for
sive fears.
Phobias.
Such
building.
compul-
fears often frustrate the sexual act.
In the
"
"
phobias
fear arises
in
connection
with certain definite conditions. It is impossible to draw

a sharp distinction between the states described above and
those of phobia, as they are often intimately associated.
But the phobias are always characterized by the sudden
appearance of pronounced anxiety in connection with the

idea of fear.
When
subjected to them, patients

may suffer from palpitation of the heart, become pale,
tremble, have a cold sweat, nausea, faintness, polyuria,
general
weakness of the
legs,
and finally may even lose control of

The conditions in connection with
themselves and collapse.
503
which such attacks of fear arise are varied, yet there are
some forms which recur with notable regularity. Sometimes
the same patient may suffer from a whole series of phobias.
The best known of these is agoraphobia, in which there is
great fear of public places. Patients are unable to walk
down a long, broad street or in a place where they are alone.
When they attempt this, they are so overcome that they can-
not proceed.
When
the condition
is
extreme,
they are
afraid to go out on the street at all, some even remaining in

bed. Closely related to this is the fear of height which pre-
vents patients from standing near a railing, on the brink

of a precipice, going over bridges, or of being in a theatre.
Among other morbid fears might be mentioned that of
being alone in the dark, riding on trains, and going through
These patients find no pleasure in travelling, do

not enjoy going to church, and always sit near the door,
tunnels.
Various phobias
may develop in connection with the occupation of the patients; for instance, barbers sometimes suffer these attacks
ready to
fly at
the
first
sign of danger.
they see a razor, or telegraphers when they

catch sight of their instruments, etc., which finally necessitates giving up the occupation.
whenever
Among women,
especially, there occurs the fear of dirt
(mysophobia), contagion, or infection. The countless bacteria always present in the air are one of the chief sources
of annoyance.
of the
bad
air
The patients are everywhere complaining

and throwing up windows; they are afraid
of handling brass or copper, or are always taking things up

by nails or pieces of glass. They notice in their food a
shining bit which may possibly be a pin. Books, especially,

Occasionare avoided as a possible source of contagion.
a
of
fear
has
the
ally
destroying something of value.
patient
One lady was always
in fear of throwing
some important
504
letter into the fire or destroying
it,
and
for this reason care-
fully avoided touching any paper and finally even printed
books. Patients are constantly washing themselves, and

are fearful of disease from touching money, books, or papers.
In taking food they have to wipe the dishes frequently and
inspect carefully every morsel.
As the result of fear of misplacing something or of soiling
themselves there develops the fear of contact, delire du
Patients throw away all the needles in the house,

toucher.
and they give up sewing for fear that they may injure themselves.
They no longer wash the windows, because the glass
break
and cut them. They refuse to shake hands,
might
but wear gloves and open windows with their elbows. They
begin the habit of washing not only their hands, but also
all of their clothing.
Some patients spend the entire day
in dressing, undressing,
A common
crises.
characteristic of almost all phobias are the
As soon
as one threatens to do that feared
patients or to hinder
means
them from
of protection, they develop
excitement.
until
and washing.
and oppose any

Impulsions.
fears apparently
however, we
carrying out their usual
an anxious condition with
how
It is quite astonishing to see
now hoping for relief of the
still
real
by the
disease,
patients,
suddenly turn about
attempt at combating
it.
In this last series of cases the compulsive

take the form of impulses. In reality,
have to do only with
fears
which are
di-
rected against the dangers that the patients suppose are

threatening them. Such questions as the following press
"
themselves upon the patients
What would happen if you
should undertake to do this or that, if you should kill some
:
one with that knife, or set that building on fire, or shout

"
aloud in church ?
Whenever they see sores or ulcers they
feel
impelled to touch them, and at the sight of
filth
must

wallow in
it.
It
505
seems to them they must smear every-
Religious anxieties create the idea of

thing with urine.
fouling the communion bread, or of bringing it in contact
with the genitals. Other patients think that they must

bore nails into the heads of their children, cut off their heads,
commit sexual
upon them, steal the silver from

open their own abdomen or that of others.
assaults
the table, or rip

Usually these thoughts arise in connection with beloved
ones.
Sometimes
illusions are associated
with these ideas,
when
the patients see a bloody knife suspended before

their eyes, are followed by a picture, feel as if their arms
and hands are extending out
to grasp a pile of
filth, etc.
all objects, which can call up

The patients no longer venture
attend communion and show the greatest anxiety when
Thus, there arises a fear of

impulses of these kinds.
to
coming in contact with dangerous weapons.
Many patients
permit themselves to be locked up or to be bound, in order

In reality, howthat they may withstand these impulses.
ever, these patients never perform the dreaded acts; at
it only happens that they are unable to withstand
most
the temptation to flee from some religious ceremony or

during prayer to substitute some blasphemous or obscene
expression.
The consciousness of all these patients is entirely clear.
They have an insight into their condition, and the desire,
but not the strength, to free themselves from it. They know
well enough that no real harm threatens them, but that they
"
fear of the fear." Their
are overwhelmed only by the
emotional attitude shows anxiety which often is in marked
contrast to their courage in real danger. They are usually
In their behavior and actions
of a weak, dependent nature.
they frequently show nothing abnormal, and control themselves perfectly before strangers.
506
Course.
The course
of the disease varies
much.
Com-
plete disappearance of the symptoms seldom occurs, and

then only for a short time, but rapid improvement is often
noticed, usually during the period of development.

The prognosis in general is unfavorable.
Prognosis.
Occasionally, especially in cases of simple compulsive ideas,
agoraphobia, and the allied symptoms,
the
disturbance
may disappear for longer or shorter periods, but there is

great fear of relapses. There are many cases in which striksymptoms appear temporarily only under the influence of
In the folie du doute and
specially unfavorable conditions.
ing
the fear of contact there
chance for improvement.
is little
On
the other hand, compulsive insanity never develops into

other psychoses, as the patients often fear.
Treatment.
The treatment
is
chiefly directed to
com-
In youth careful
bating the condition of degeneracy.
attention to the demands of physical development is necesThreatening peculiarities should be warded
off by
and
all
deleterious
influences
removed
training,
which tend to weaken the physical and mental powers of
The symptoms of the disease can be combated
resistance.
by persistent and patient training with a view to strengthening and encouraging the patients to struggle step by step
against the morbid compulsion. The significance of their
condition should always be made clear to the patients, and
they must be impressed with the fact that they will overcome it more by abstraction and diversion than by exercise
sary.
careful
of will power.
Occasional interviews with the physician
aid in quieting the patient and giving
him
additional cour-
be of value during crises
age.
Hypnotic suggestion may
in supporting the patients, but its influence
is
transitoiy.

E.
507
IMPULSIVE INSANITY
Impulsive insanity is characterized by the development of

morbid tendencies and impulses which either dominate over
volition continually or in recurring
paroxysms.
which appear without motive, are performed

because of an irresistible impulse. The impulses do not
arise as the result of a conscious plan, but appear suddenly,
These
acts,
are quickly executed, and often quite indefinite, thereby

causing the actions to appear unpremeditated, purposeless,
and even absurd. In case the act is serious or dangerous,
accomplishment may be preceded by a conscious struggle.

But yet the worst acts are often performed without delay,
and as a matter of course. Neither the regret that follows
its
the act nor the fear for the results suffices to suppress the
recurrence of similar impulses.
Those so-called normal individuals
who suffer from triwhich

fling
insignificant impulses,
appear only under
certain circumstances, disappear rapidly, and lead to very
simple acts, represent a sort of transition stage between normal health and impulsive insanity. Maudsley tells of a man
who for weeks was annoyed by an impulse to overturn two
stones which lay upon a wall, finally forcing him to sneak
and
out at night in order to perform the absurd act.

pulses become of more consequence to the patient
are constantly involving the environment
and
Such im-
when they
interfering
The impulses that develop in

are of far more importance.
with comfort and occupation.

certain
definite
directions
These include the impulse

destroy or
to
tramp,
to set fire, to steal,
and
to
kill.
In the impulse to ramble the patients are suddenly seized

with an intense desire to roam about, sometimes in connection with some sort of an adventurous purpose.
So they
508
wander about here and there
until their
means are exhausted.
They have a clear memory of their experiences, and they do

not see anything peculiar in their conduct. Occasionally
during these periods they commit
all sorts of
frauds,
assume
names, and are boastful.

The impulse to set fire (pyromania) is exhibited espeSomecially by young females, most often during puberty.
times the morbid pleasure of seeing things burn and at
false
hearing the crackle dates from early childhood. Another

common form of impulse is the tendency to skilful but foolish stealing
(kleptomania), encountered almost exclusively
among women, and especially during menstruation and

pregnancy. The stolen articles are frequently almost or
quite worthless for the patients.
In some cases there
some one
is
definite thing which

accumulated in
Sexual
impulses may accompany this
great quantities.
Further expressions of degeneracy of normal
condition.
desire for
impulses are seen in
tendency to play,
many
is
silly
marked
fondness for animals, irresistible

increase of sexual impulses, and
similar digressions.
Morbid impulses to destroy and kill are other instances.

There is a special group of young women who show a morbid
impulse to beat little children intrusted to their care. Here
there exists a close relationship to those sexual impulses
which have been called sadism, masochism, and fetichism.
The men who prod women, who snip hair, slash ladies'
dresses, steal women's shoes or linen, and many exhibitionists
belong to this class.
The mental endowment of these patients usually shows no
marked defect, but in some severe cases there is a more or
high grade of mental weakness. In the emotional field

the defect is more evident; the patients are apt to be child-
less
ish,
unstable, shy, seclusive, or vulgar.
The symptoms
Course.
ing
certain
of
periods
of the disease appear only dur-
life,
and
particularly during the

time there is a condition
period of development, at which

of lessened resistance in both the physical and mental
In some cases there

tal
is
509
fields.
improvement, with physical and menof a stable personality.
development and the formation
Periodicity
is
noticed only occasionally.

One should not confound the ineradicable
Diagnosis.
relapsing of criminals with the regular repetition of similar
criminal acts in these patients. The criminal sets fire, kills,
and
from selfish motives, and for some

definite purpose, perhaps to do some one injury, while the
patient suffering from impulsive insanity is forced by the
dominating impulse to the deed against his will. Frequently
steals,
but he does
it
the patient has a feeling that the action
is
inconsistent, un-
and morbid. Compulsive insanity is distinguished

the
fact
that the patients do not commit deeds that are
by
in their minds; they often have an abhorrence of them and
natural,
to something which really does not

In impulsive insanity there is apt to be associated
exist.
with the idea of the morbid act a feeling of desire and
fear that they
eagerness for
main quiet
may yield
its
until
performance, and the patients cannot redone. The performance of the act is
it is
immediately followed by a feeling of
relief,
while failure
brings disappointment.
Treatment.
rally lies
adapted
The treatment
of impulsive insanity natu-
in the education of the patients, which must be

to individual cases and carefully conducted, with
proper regard for the physical development. It is of greatest importance that the patients do not become addicted to
the use of alcohol.
There are some cases which, for the proan institution where
tection of society, need to be confined in
they can be educated to lead a useful
life.
510
F. CONTRARY SEXUAL INSTINCTS
This psychopathic state, which received its name from

Westphal, refers to those sexual propensities, appearing
mostly in youth, exhibited by individuals of the same sex

with an indifference or even an abhorrence
for each other,
The condition has
of the opposite sex.
also
been well
described by Krafft-Ebing, Moll, and Schrenk-Notzing.

The contrary sexual instincts are far more
Etiology.
an uncommon condition, the

cases reported to date numbering but a few hundred,
although homosexual patients maintain that it is by
no means rare. Ulrichs, in his own morbid experience,
claims to have encountered two hundred cases. It is
more prevalent in certain employments, such as among
among men.
prevalent
It is
decorators, waiters, ladies
people.
Moll claims that
tailors;
also
among
women comedians
theatrical
are regularly
homosexual.
The condition develops from a
state of degeneracy.
It
a view of Krafft-Ebing, emphasized by the statements
is
of the patients themselves, that the peculiar perversion of
Schrenk-Notzing, on
congenital.
some
stress
hand, lays
upon accidental factors
which happen to exert an influence upon the sexual feelsexual
the
impulse
is
the other
ings long before the age of sexual development, such as

the intercourse of naked boys while bathing, wrestling, etc.
Sometimes passionate friendships

dren
1
who
are
still
Westphal, Archiv
v. Krafft-Ebing,
f.
exist
among young
ignorant of the sexual differences.

Psy., II,
chil-
But
1.
Psychopathia Sexualis, 1900.
Moll, Die contrare Sexualempfindung, 1891.

Schrenk-Notzing, Die Suggestionstherapie bei krankhaften Erschei-
nungen des Geschlectssinnes, 1892.
511
only with the abnormal child that such accidental

influences upon the early sensual feelings can have any
it
is
in the later development of the sexual impulses.

It
seems most probable, then, that the morbidity of the condition depends not upon impulses which are perverted
power
from the onset, but upon a characteristic tendency
origi-
nating in a hereditary state of degeneracy.

Sexual impulses develop early and
Symptomatology.
usually to a marked degree, sometimes leading to onanism.
The natural heterosexual impulses may have developed

first, being displaced later by stronger morbid tendenThe patients, both in the waking and dream states,
cies.
experience
tion
sexual
pleasurable
with their
own
sex.
feelings
Attempts
only in connecnatural sexual
at
intercourse are unsuccessful, or accomplished only with

Close associations are usually formed with
difficulty.
some individuals
into
same
sex, which usually develop

with
passionate friendship,
extravagant display of
of the
affection, letter writing,
exhibitions of jealousy.
sending gifts and flowers, and

This frequently extends to kiss-
embracing, and occasionally to masturbation and

other forms of sexual perversion, but rarely to pederasty.
In these friendships the physical and mental superiority
ing,
of one individual over another
may
aid in arousing the
Usually both individuals are homosexual,

but sometimes the patient desires intercourse only with
a normal individual. Frequent changes of the affection,
sexual feelings.
with disruption of these friendships, often occur, showing

the fickleness of the patients, though in some cases such
relationships
social
rank
uals.
is
are
maintained
for
of less importance
years.
Differences
in
than in normal individ-
few patients of the better classes are attracted
by mechanics, and
especially
by
soldiers.
512
The patients usually remain unmarried. Those who do

marry, either in the hope of overcoming their perverse
tendencies or from the desire to have children, are usually
true to their marital duties, except in the matter of sexual
Some
intercourse.
regularly, in
indulge occasionally, but most of
them
homosexual intercourse.
Other symptoms indicative of a morbid constitutional

basis are usually present, especially the physical stigmata.
usually unimpaired, as well as the ability to

comprehend, but there is an increased sense of fatigue,
lack of perseverance with mental work, and a tendency to
Judgment
dream.
is
Imagination
is
prominent and interferes with the
capacity for purely rational activity.
Some
are especially
in an artistic way, being good musicians and

but they also possess a keen sense of appreciation
Mental weakness may exist. Many
of their abilities.
have
an
insight into the morbidness of their impatients
endowed
artists
and defend themselves on the ground that the

impulses are the natural and involuntary product of their
pulses,
In the emotional life they present irritability,

constitution.
are sensitive, moody, and impressionable, often timid, and
given to passionate outbursts of feeling. In actions they
appear effeminate, vain, pliable, unstable, and are some-
They are often careless about their work,

The sexual imdistractible, and untrustworthy.
times sluggish.
easily
pulses are apt to gain control over them, causing neglect

Fetichism and other perversities may also be
of business.
present.
The
condition
sionally present,
of
when
psychic hermaphroditism is occasexual feelings are exhibited toward
both sexes, though usually stronger toward one sex than

the other.
individual
Where homosexuality
may
very pronounced, the

experience a change of personality, a man
is
513
becoming feminine in manner, gait, and countenance. He

becomes affected in manner, vain, coquettish, takes great
pains with his personal appearance, desires to be in fashion,
wears flowers, and uses cosmetics. Some develop a fond-
women's employment, do needlework, arrange

after the fashion of a woman's boudoir, and
rooms
their
they may even dress in women's clothes, padding the hips
and breast, talk in a falsetto voice, and in every possible
ness
for
way
simulate feminine traits.
may make
traits
Early evidences of such

A few
their appearance in childhood.
patients present physical characteristics indicative of the

opposite sex; men are beardless, possess high-pitched,
soft white skin, with a more marked
and
well-developed mammae; while the
pannicus adiposus
homosexual females have a deep, coarse voice and show a
tendency to grow beards. The former are called by KrafftEbing androgyny, and the latter gynandry. Hermaphroditism has never been encountered in homosexual individ-
have
light voices,
uals.
The course
of the disease,
which usually reaches
its full
development between twenty-five to thirty-five years of

age,
there
is
always prolonged. In the acquired homosexuality

often a long struggle before the patient becomes
is
confirmed pervert. The homosexual tendencies may

appear periodically, with or without accompanying states
of general excitement.
matter to identify
homosexual patients where there has been a marked transDiagnosis.
position
of
It
is
not a
the traits
normal sexual instincts
difficult
characteristic
may
of
the
sexes.
Yet
exist in spite of such a trans-
position.
Usually the condition becomes known to the
physician only through the communication of the patient.
It is necessary to distinguish between contrary sexual in2L
514
and mere
practice of homosexual acts, the latter

being pure perversity, as practised among prisoners, etc.,
who return to normal sexual relations upon gaining freestincts
dom.
Prognosis.
ally thought.
The prognosis is more favorable than is usuVery many cases improve, and some even
recover under the influence of treatment.
The
Treatment.
ment
is
is
most
successful
method
of
treat-
through the use of hypnotic suggestion.
directed
first
This
against the increased sexual excitability
and masturbation which
is
frequently present; next
it is
applied to the insensibility of the patient toward his own

sex, and finally in creating an excitability toward the
opposite sex
and a tendency to heterosexual intercourse.
The hypnotic influence over the patient, dealing as it does

with a deeply rooted habit, is acquired slowly and with
Schrenk-Notzing lays great stress upon regular
natural intercourse, but excessive coitus must be avoided,
because it may have an injurious effect upon the selfconfidence. Treatment directed at the general nervous
difficulty.
and should include the

establishment of a routine in the physical and mental
and relaxation.
life, with attention to the diet, exercise,
One should remember that even though marked improvement or recovery takes place, the original defective basis
condition
still
is
remains.
also of importance,
XIV. PSYCHOPATHIC PERSONALITIES

conditions which develop on a morbasis include an extensive borderland
THOSE psychopathic
bid constitutional
between pronounced morbid states and mere personal

eccentricities which are wont to be regarded as normal.
We consider personal deviations from the regular course
morbid only when they are of

special consequence to the physical and mental life; but
the distinction is one of degree and is to a certain extent
of mental development as
arbitrary.
a considerable group of such morbid conditions

which may be properly regarded as mental deformities.
There
is
They are not characterized by any definite disease process,

but rather by a general deviation from the normal mental
life.
Our discussion of this group will be limited to conspicuous types which are of special interest to the psychiatrist.
A.
The French
alienists
fact that there
BORN CRIMINALS
were the
was a form
first
to call attention to the
of insanity in
which the
dis-
the feelings and the conorder was limited to the

duct. In 1835, Pritchard grouped together, under the name
of "Moral Insanity/' those diseases in which there existed
fields of
a perverse state of the feelings, temperaments, dispositions,

habits, and actions, while the intellectual functions pre-
sented no apparent abnormalities. The possibility of a circumscribed impairment of the morals was combated by
515
516
pointing out the correlation between the different phases

of the mental life and the presence of concurrent intellectual
"
"
abnormalities, hence Moral Insanity ceased to be regarded
as a separate disease and came to be classed as one of the
sub-forms of imbecility. One of the causes of this change

of attitude was the supposedly demoralizing effects of the
doctrine on criminal law.
Daily experience teaches us that the intellect and the

emotions develop more or less independently of each other.
There
are,
undoubtedly,
men
with conspicuous mental
We
endowment who
are morally bad and vice versa.

must
that
the
of
the
admit, however,
complete independence
separate fields does not obtain. Even in congenital emotional indifference there
is
always present a certain im-
But unquestionably
pairment of intellectual capacity.
there is a large number of individuals in whom the inadequate development of the moral feelings is more conspicuous
than that of the intellect.
The doctrine of " Moral Insanity " has received new meaning through the activities of Lombroso and the Italian
positivistic school in the attempt to describe and differen-
born criminal
"Delinquente nato." According

about
to Lombroso
twenty-five per cent, of criminals, and a
tiate the
higher percentage among the murderers, carry the

of the born delinquent. It is a reasonable hypothesis
that in these conditions we have to do with various grades
still
marks
of psychopathic
degeneracy.
The
lighter forms
may
be
scarcely distinguishable from the inadequate moral development of normal life. But on the other hand, there are per-
sons whose
shocking moral incapacity clearly indicates

At the present time there is a certain
morbid degeneracy.
justification for calling the severest
dowment " Moral Insanity"
forms of criminal en-
or "Moral Imbecility."
But
PSYCHOPATHIC PERSONALITIES
517
more exact characterization of the various conditions

which have hitherto been collectively designated by this
term would help to clarify the matter; for instance, it
would be advisable to differentiate between those who
suffer from constitutional excitement, the unstable and the
morbid swindler, and the group which we are here describing
and which is characterized in general by moral stupidity.
The general causes of this type of degeneracy

Etiology.
are practically the same as those which we have come to
regard as the causes of degeneracy itself. Alcoholism in
the parents easily stands first. Among two hundred inmates of a reform school seventy-eight had drunken fathers;
five, drunken mothers; and in two cases both parents were
drunkards. There were also twenty-four cases in which
from mental disturbances, twenty-six

and
many more from other nervous diseases.
epilepsy,
The correlation between illegitimacy and born criminals
parents
suffered
from
is
partially accounted for
ity
and
by the presence
of defective hered-
of alcoholism in the parents.
together with the prevalence of stigmata and

the unresponsiveness of the genuine criminal nature to all
These
facts,
educational influences, indicates the existence of a certain
group of cases with abnormal endowment gradually mergMoreover, some of these patients after
ing into disease.
a long criminal career develop severe psychoses which lead
to deterioration, especially the paranoid forms of dementia
prsecox.
Symptomatology.
The
intellect of
these patients
is toler-
ably developed within the limits of practical life. They

comprehend well, acquire a certain amount of knowledge
and experience, which they may exploit with some craftiness
they show no defect of memory and are fairly logical

But their views are narrow. They cannot
in their thought.
518
perform exacting, intellectual work and are unable to develop any coherent conception of life. Experts on criminal
natures have demonstrated a decided lack of comprehenBorn criminals do not feel the
sive reflection and foresight.
need of reflecting beyond the present and the more immediate future.
Even
youth there are conspicuous moral defects,

such as a lack of sympathy, shown by barbarous cruelty to
in early
animals, malicious teasing, illtreatment of their playmates,

and general unresponsiveness to kindness. Later there
develops pronounced selfishness without sense of honor or
proper affection for parents, brothers, and sisters. Here

belong those monstrous children who even at the tenderest
age try to murder the members of their family for trivial

reasons, and then report in a stupid, matter-of-fact way the
details of their plans,
at
failure.
and show obvious

education are
Attempts
most important incentives
ing.
Force alone
is
love
regret at their
fruitless, since the
and ambition
are lack-
able to suppress the manifestations of
soon met by duplicity,

cunning, deceit, callousness, stubbornness, and a disposition
Patients manito lie. Development throughout is selfish.
their unbridled selfishness,
but
it is
and companions
only when they anticipate some advantage from it. The
fest affection
toward parents,
relatives,
itself in
vanity, braggadocio, peevishness,

love of idleness, excesses, foolish prodigality, and often
in weak sentimentality.
Usually, there is little resistance
egotism expresses
to temptation
emotional
bility,
and
and sudden impulses, and there
irritability,
vindictiveness,
is
great
insta-
unreliability,
susceptibility to alcohol.
It is evident that
such an endowment
necessarily to a criminal career.
truancy, loitering, begging,
will lead
almost
It usually begins
and petty
with
larcenies, oftentimes
519
in connections with gangs, and, in females, with prostitution.
Often this leads to commitment to reform schools.

"children of the well-to-do classes
Such
shock their parents at an
by vulgarity, lying, persistent laziness, petty larand

cenies,
They wander from one teacher
peculations.
to another, always with the same lack of success, until
finally it becomes impossible to protect them from the reearly age
sults of their conduct.
The
is
further
of these morally incapable personalities
life
a constant conflict with society.
selves thoroughly out of
They soon
find
them-
harmony with any social environ-
ment in which they are located. But they are wholly

unable to appreciate that it is their own actions which necessitate their being
and
condemned
penitentiaries.
They
to pass their lives in prisons

rather consider themselves mar-
who
are cruelly persecuted, while others, no better than

they, live in honor and wealth. They regularly fail to comprehend the probable outcome of their lives. They are contyrs
vinced that
when they
it will be possible for them to succeed, even

are determined to return immediately to their
old ways. Many submit with cringing docility to imprisonment, while others even in confinement continue their
struggle against the regulations of society by insubordinaBut as a rule they are cowardly
tion, deceit, and treachery.
and less inclined to open violence than to passive opposition

and to treachery. They are frequently hypochondriacal,
and there is often an increased susceptibility to bodily pain.
Their inaccessibility to friendly advances
From
majority
this
of
class
of
quite noticeable.
defective individuals the
is
morally
"professional criminals"
criminals derive increasing pleasure
from
originate.
conflicts
with the
on their performances, and

conscious effort to develop themselves for their art.
laws, pride themselves
These
show a
Thus
520
cunning and
ingly
their criminal acts
heedlessness
"
who become exceedBut it is a notable fact that in

they often show an astonishing degree of
there develop criminal
'
specialists/
skilful.
and lack
of
foresight.
Evidences
of
pro-
nounced physical degeneracy often accompany the criminal

natures. There are no definite and inevitable deviations,
but there is a considerable group of signs of degeneracy,
which show unmistakably that confirmed criminals often
possess an inferior physical endowment. The number and
variety of these signs are certainly more apparent in criminals than in the general population. This fact of itself
naturally proves nothing in an individual case. A given
person may, therefore, be mentally sound in spite of numerous signs of degeneracy. On the other hand, we would expect a larger percentage of mental deviations in men of that
To be sure
sort than in those who present no stigmata.
on
account.
do
not
that
need
to
be
criminals
Rather,
they
the born criminal is only one of the forms in which degeneracy expresses
Diagnosis.
itself.
It is exceedingly difficult to
between health and
draw a sharp
Hence, judges of the

" moral imcourt especially combat the assumption of a
But the existence of the moral incapacity exbecility."
tending back into early youth, in spite of satisfactory
line
disease.
development and the complete unresponsiveness

of the patient to all moral influences, justify the assumption
intellectual
morbid personality. Moreover, the existence of numerous and definite signs of physical degeneracy, as well as the
of a
history of injurious prenatal influences, such as alcoholism

or mental disease in the parents, are significant, but in any
individual case they are of value only as indicating the

necessity of a careful scientific examination of the mental
condition,
and are not proof
of disease.
It is a notable
521
fact that many of these patients fail to show any striking

disturbances during imprisonment or while confined in institutions, but their great incapacity at once becomes evi-
dent as soon as they are released and exposed to the
numerous
vicissitudes of
life.
The treatment
Treatment.
of
bora criminals unfor-
little opportunity and still less prospect of

a quiet, rigid, but at the same time kindly
education in a limited sphere, preferably under psychiatric
tunately offers
success.
If
supervision,
does not succeed, the individual cannot be
prevented from entering a criminal career. Lombroso has

advocated the view that many of these persons under favorable conditions need not come into conflict with the law, but
may gratify their criminal tendencies in other and incontrue only of the lighter
forms, which closely approximate health. Baer reports that
occasionally children who were originally emotionally de-
spicuous ways.
ficient
This, however,
have later in
life
is
improved considerably.
It is also
a well-known fact that some of the criminal tendencies

that appear early in life, such as the propensity to lie, to
steal, and to cruelty, can almost completely disappear as
the patient matures mentally.
In later life the best that
one can do
to compel the person to follow a regular occupation under proper control, to choose proper associates,
and finally to abstain from alcohol and sexual excesses.
is
Unfortunately, this can be carried out successfully only

in the light cases.
B.
THE UNSTABLE
The "unstable," as the French call them, constitute a

second large group of psychopathic personalities which are
characterized by a weakness of will in all their activities.
The intellectual endowment may be
Symptomatology.
522
very good, but is often only mediocre. Some patients

astonish one by their rapidity of comprehension, their ease
of committing things to
press
memory, and
Patients
themselves.
are
their ability to ex-
often
keen observers,
quickly recognizing the defects and peculiarities of their environment, are vivacious and understand thoroughly how to
use their information to the best advantage. On the other

hand, they lack altogether energy for continuous and satis-
out zealously, but soon grow

weary and are, therefore, unable to complete any course of
education. They never probe to the bottom of things and
factory work.
They
their
is
is
knowledge
start
superficial
often readily acquired but
and fragmentary.
Knowledge
not elaborated and, thereAt school their talents someis
fore, is quickly forgotten.

times arouse great expectations, which are never
because of their inconstancy and unreliability. It
fulfilled
is
often
"
They could do much better if they

only would," but unfortunately they lack the power to will.
said of such children,
Higher
intellectual
development
is
always
defective.
confused and indistinct, judgment is immature and onesided, and the understanding of life un-
Conception
is
developed and short-sighted.
Their interests center on
sports and on frivolous pleasures, and they do not respond

to more serious matters. They often show a propensity
to dream, to poetical or dramatic efforts, etc., but they are
never earnest or thorough.
In emotional attitude the patients show abrupt changes, at

times being elated and confident, and at others spiritless,
They are very easily aroused to

as
and
enthusiasm,
readily disheartened. There is usually
an increased irritability, sensitiveness, and peevishness.
They are offended and dispirited upon slight provocation,
are suspicious and prejudiced, but one can easily put them
sensitive, or pessimistic.
523
good humor again. Very often their relations with their

become strained. The patients often become
dissatisfied and embittered, the cause of which in their
opinion never lies in their own behavior, but in the unkindinto
relatives
ness of their people.
Although they are generally harmless
and good natured, they are dominated by the most pronounced selfishness. Their own welfare is their chief concern, while they show little interest in their environment
and even less sympathy. They are not inclined to submit to privation, but demand comfort and luxuries, and
as
gratuitous insult. They often

show vanity in the effeminate care of their personal appearance, their affected utterance, and tendency to braggadocio.
The patients' lack of perseverance, of power of resistance,
regard
all
restrictions
and energy usually becomes evident as soon as they are

deprived of home influences. At school they are considered pliable, unstable, and easily led off into foolish
pranks, but they are susceptible to education, which, howAs soon as they have to stand on their
ever, does not last.
own feet, they are helpless. Since work is not agreeable,
they often change, hoping to find an easier occupation.
They lack punctuality, neglect their business, do not work
full hours, and allow little things to interfere with fulfilling their
obligations.
They excuse
their unproductive-
ness in various ways.

In one place the work is stultifying,
in another too strenuous, the shop is unsanitary, the foremen are too severe, etc. Conditions of emotional excite-
ment
are aroused
by
ridiculously trifling occurrences
and
prevent the patients from working; under no circumstances

can they continue work, they must cool down, and must
seek diversion by going to the theatre. They are often hypochondriacal, are deeply concerned for their health, feel
exhausted, have headaches, or a feeling of faintness as soon
524
as they are set to work. Hence, they are frequently discharged as useless, or at most are tolerated as unpaid assistants,
and are wholly incapable
of obtaining
an indepen-
dent livelihood.
They are usually not ashamed of this state of affairs. They

see no impropriety in being supported by others, and believe
circumstances justify their conduct. Even though they
earn nothing, they are careless with their money, buying
amounts without thought of the
useless articles in large

future.
They
readily
yield
to
temptation.
If
placed
under
guardianship, they become slack, indolent, and unproductive, but they lead their useless lives without gross disturbances, tend to fill them with loafing and useless fads,
take cures
weary.
when not
sick,
and seek recreation when not
In bad company, they give themselves up to sexual
extravagances, get diseased, and begin to drink and gamble.

Under these influences they sometimes do very questionable
things and even perform criminal acts. Such patients
sometimes develop the picture of "pseudo-dipsomania"

They may abstain for months and then upon some occasion
when their weak
will is
overpowered, they begin to drink and
continue drinking until thoroughly intoxicated and their

money is all gone. It is not their emotional condition
that impels the patients to drink, but mere incidents, such
as an intimate friend or a farewell banquet. The de-
bauches are not periodical, but are determined by external

circumstances. Moreover, the patients are not excited by
the alcohol, but are simply intoxicated.
Lighter grades of this weakness of will are very common.

large proportion of those whom Aschaffenburg calls
A very
"habitual criminals/' and particularly a large number of

tramps, mendicants, and even prostitutes belong to this
525
group. The instability first becomes evident as soon as

these individuals encounter some difficulty in their lives.
Investigation shows that a large number of vagabonds are
forced into their life by their congenital instability and not
by unusual circumstances. The same condition is clearly

shown to exist in the offspring of well-to-do parents, who,
notwithstanding an apparently good endowment and good
education, continue wholly unstable. One rarely fails to
find in these families traces of degeneracy.
Diagnosis.
The gradual appearance
of the
symptoms
of instability, as the patients attempt to undertake the

duties of life, resembles somewhat the picture of dementia
But without question they are two
prcecox.
totally different
conditions.
Instability often leads to idleness and abandonment of certain lines of work, but never to dementia.
The condition of the patients remains essentially the same
as it was in youth; they are not dull and apathetic, but
only afraid of work. They retain their hobbies and always
feel the necessity of passing the time in some agreeable
way. Notwithstanding their perverted and onesided ap-
prehension, they develop neither delusions nor hallucinations.

Finally, the patients are natural in their manners;
their will is
weak and
yielding,
but never shows eccen-
tricities.
Other forms of the insanity of degeneracy sometimes

resemble the unstable; for instance, the increased suggesThe unstable do not show
tibility reminds one of hysteria.
the extensive influence of the emotional states
upon the
physical processes, although there are occasional hysterical

symptoms. Like the born criminals the unstable present
great
susceptibility
to
temptations,
distaste
for
work,
superficial intellectual work, lack of foresight, selfishness,
and are often enough impelled
to criminal careers.
Never-
526
theless, it is better to distinguish the
pathic personalities.
The unstable
two forms
of psycho-
lack the passion and
persistency characteristic of the born criminal ; there is no

trace of the independent criminal will and of professional
warfare against social order. When the unstable commit

crimes, they are the result of opportunity and temptation,
and are limited to actions which demand neither resolution
nor energy.
Treatment.
Since this disease represents a form of

degeneracy, the treatment is limited. The value of educational measures in individual cases, such as afforded by
strict
ment
regimen in the performance of duties and developdepends on the severity
of physical capacity for work,
of the disturbance.
In later years sanitarium
helpful, where it is possible to remove

inhibitions and to direct employment.
patients rarely possess sufficient
life
sorts of
all
be
morbid
may
Unfortunately, the
determination to submit
to compulsion for any length of time. In some cases total

abstinence from alcohol causes great improvement. Under
favorable circumstances
it
is
sufficient
protect the patients against relapses for

C.
if
one
is
able to
some time.
THE MORBID LIAR AND SWINDLER
The morbid
liar and swindler

the "pseudologia phanhas been described by Delbrueck. This disorder
consists of a morbid hyperactivity of the imagination, in-
tastica
"
accuracy of memory, and a certain instability of the emotions
and
volitions.
Symptomatology.
At
first
glance these patients often
They apprehend quickly, easily

situations, and readily acquire special
information, such as geographical and historical data,
citations from poets, and even foreign languages.
They can
appear specially gifted.
comprehend new
527
converse fluently on the most varied subjects, have heard

and are sure in their judgments.
They thus give the impression of being cultured and well
of almost everything,
read, but in reality their knowledge is very superficial and

made up of isolated, incoherent scraps, and a mixture of
which are
details,
insufficiently
rated and at times even
and
their conception of
There
is
falsified.
and coherence;
system, order,
life
comprehended and elaboTheir thought lacks
judgment is immature
shallow and insincere.
their
associated with the susceptibility to
new
impres-
an extraordinary mobility of the content of memory.

But both of these symptoms are an expression of one and
the same fundamental disturbance; namely, an increased
sions
lability of
wishes,
the psychic
processes.
and accidental impulses
ences of
life
alter
Recollections,
and
in various ways, so that
moods,
color the experi-
before long there
appears an inextricable mixture of truth and fiction. In

morbid liars these fabrications and falsifications of memory
appear on a large scale. At first there may be an indistinct
feeling of uncertainty as to their statements, but very
soon the actual and invented details become so mixed
that the patients themselves are no longer able to account

for their real origin.
The
specially characteristic feature of
morbid lying
satisfaction which the patients derive from wilful
is
the
falsifications
"joy of lying." They are very apt to embellish the most unimportant statements with alterations
of
memory
the
and additions indeed, they often cannot tell a story twice

alike.
The activity of their imagination enables them to
;
fancy unreal occurrences in a dreamlike fashion ; they think

of themselves as participating in them, and finally they
recount them as actual facts, clothed in varying forms.
In this way patients come to involve themselves in a maze
528
and narrations from which there is no other

escape except by new falsehoods. The most extraordinary
experiences are related in a most matter-of-fact way, with
of statements
a cautious secrecy or with outbursts of emotion;

their descent
such as
from royal
families, dangerous experiences,

unheard-of
incidents like those encounpowerful enemies,
tered in dime novels, etc. Indeed, many details may be
borrowed directly from their reading. The content of

these fabrications can change according to need or fancy.
Yet some elements tend to recur. In spite of appearances
the patients do not present genuine delusions. They know
well enough that they are fabricating, but allow themselves
away by their material, and keep on spinning

They are soon forced by the contradictions with
earlier utterances to new fabrications, but even with-
to be carried
it
out.
their
out this they are unable to withstand the impulse to give

sway to their imagination on every occasion. For the
full
time being they completely forget the distinction between

reality and fiction. When confronted with their lies, they are
and promise to do better, only to justify their

conduct by a new tissue of fantastic lies; or they disavow
outright their early statements, assuming the attitude of
either contrite
injured
innocence
and
declining
further
discussion.
If
they can gain a little time in this way, they very soon astonish one by further disclosures.
In emotional attitude the patients are usually high spirited

self-conscious.
They live from one day to another in
and
a wholly indifferent manner, have no care for anything,

trust their star, are thoughtless,
jokes
and pastimes.
At
and are always devising
intervals
there
are
occasional
dramatic outbreaks of despair or of angry irritability.

Any criticism of their pretensions is apt to be met with
real excitement,
but such emotional fluctuations are usually
529
and soon give way to the usual self-complacency.

Patients show absolutely no insight, but, on the other hand,
consider themselves specially gifted, clever, and boast most
superficial
impressively of their family connections, liberal education,

and prospects. They lay the blame
brilliant attainments,
upon adverse circumstances,

inadequate support, or the hostility of relatives, etc. Even
for
any apparent lack
of success
in their simplest narratives, they are easily led into apparent
exaggerations.
In conduct patients are clever, confident, and presumptuous. They are uncommonly curious, like to participate in
everything, and understand how to make an impression,
and to inspire common people with confidence and respect.
They have a tendency
to gossip, to read
much, and to busy
themselves, but not persistently, and they are fond of pleasLeft

ures, dissipations, entertainments, and gay society.
to themselves they are prone to live an irregular, extravagant,
and prodigal life, are exceedingly polite, dress in the latest
fashion, and lavish their money on trifles.
With this sort of an endowment these morbid patients are
naturally impelled to the career of swindlers and tramps.
The tendency to swindling of all kinds appears even in early
youth. Thirst for adventures leads patients to undertake

adventurous journeys, during which they employ their gift
for lying to make credulous people believe their fabulous
tales concerning themselves, their past history,
and
their
future prospects, and to lure money from their pockets.

They know how to conceal their real personality so that it
often impossible to expose them. They are especially
apt to pose as scions of a famous family, who have been
is
compelled by various circumstances to flee and to conceal

themselves, but they have the prospect of securing great
riches.
They know how to establish the probability of all
530
by all sorts of dodges, such as forged letters and papers.

They swindle every one possible by relating to them pathetic
stories.
They present themselves as colleagues, turn up
under different names, and use high-sounding titles to order
this
Their procedures resemble those

of the ordinary swindler, but it is noteworthy that these
patients swindle in reference to things of little consequence
merchandise of
all
kinds.
and often get no advantage out of their representations.

Many patients simply wander about acquiring a livelihood
by irregular but respectable occupations, boast and lie for
no other purpose than the mere pleasure derived from
their falsehoods and impressions which they make on their
surroundings.
Morbid swindling and lying are also forms of degeneracy.

They are very often accompanied by definite hysterical
symptoms. However, they should not be regarded simply
as a type of hysteria, because they often occur without
Moreover, they are in some respects
hysterical symptoms.
related to the group of the unstable; indeed, there are even
There
transition forms into that group.
is
some
really
question as to whether these patients should not be included in constitutional excitement. While it is probably as
difficult
to
degeneracy,
draw sharp
still
be the cue.
Great
fondness
It is lacking in
for
forms of
prominent psychomotor excitement
distractibility,
restlessness
lines here as for other
new
indicate
morbid swindling and
marked
irritability,
undertakings,
great
constitutional
may
lying.
loquacity,
and
instability,
excitement,
in
which
fabrications often occur but are not necessarily concomitant

symptoms. On the other hand, fondness for invention of
details, dignified
manners, a great
gift for fabrications
accompanied by excitement, and the
un-
clever ability to take
advantage of credulous persons, are rather the charac-
531
born swindler. It seems of special importance that in constitutional excitement the tendency to
swindle appears at a certain time and may show definite
teristics of the
exacerbations, while in born swindlers it is a permanent

personal peculiarity. Also, the occurrence of frequent and
sudden changes of disposition, especially periods of causeless
dejection and despair, favors the diagnosis of constitutional
excitement.
The prognosis and treatment of the morbid swindler and

are the same as that indicated in the related forms of
liar
the insanity of degeneracy. Many of these patients cause

so much trouble that they require permanent custody.
D.
THE PSEUDOQUEBULANTS
The pseudoquerulants comprise a group of morbid personalities whose conduct resembles somewhat that of
genuine querulants (see p. 432), but who never develop
genuine delusions. Whether these pseudoquerulants comprise a
The
ocre,
uniform group
is
undecided.
intellectual capacity of the patients is usually
but
is
medi-
sometimes very good. As a rule they possess a

which enables them to utilize any ad-
certain craftiness,
vantage and to correctly comprehend the weaknesses of

their opponents; some show a tendency to quibbling and
Memory is generally good, however; its

often
suffers because of personal coloring.
The
accuracy
memory of earlier events is unconsciously modified in accord
hairsplitting.
with their emotional needs.
irrelevant, tends to exaggerations, is in
and influenced by intense
also
biassed,
many ways
perverse
Judgment
is
Hence persons and

feelings.
conditions are often incorrectly judged. Patients themselves are often uncommonly credulous ; that is, ideas and
532
communications which correspond to their tendencies and

views are considered correct without further proof, but if
they do not conform to their desires, the patients oppose
them with the most extreme and obstinate distrust.

This marked personal influence over apprehension, memory, and judgment arises from an increased emotional
The patients are very passionate and become
irritability.
greatly excited over
trifles.
They regard every
real or ap-
parent infringement upon their rights as gross injustice,

which they believe themselves justified in combating with
the keenest weapons. They are, therefore, revengeful and
persistent in their hostility, regard every opposition as a
personal matter, are always ready to impute to their adver-
and
to carry on their fight in

Associated with their passion there is
saries dishonorable motives,
every possible way.

a marked egotism. Patients regard themselves as especially
and superior to their environment, and are also

to
consider their own affairs as matters of public
disposed
intelligent
importance
that they themselves are champions of an

Hence even trifling affairs lead to long-
important cause.
drawn-out
litigations,
because they
fight to the finish for their rights.
feel
under obligation to
The combination
of sen-
and arrogance inevitably inmany difficulties and conflicts with their
sitiveness with recklessness
volves patients in
There
innumerable misunderstandings
and provocations which gradually involve them in a perfect
environment.
maze
arise
Patients follow up, as far as they

possibly can, each affair with bitter determination. They
do not rest with the judgments which are handed down,
of complications.
reject favorable settlements, appeal to higher courts,
and
seek to interest the public in their suits. They do not give

up the fight until every possibility of success has disap-
peared; however, they sometimes renounce beforehand the
533
most extreme measures, if the disproportion between the

prospect of triumph and the probable cost is very great.
Then they attempt to obtain satisfaction in other ways,

by charges of forgery against the witnesses, who have not
agreed with them, or by petty denunciations, false dealings,
slanderings, etc.
These give
rise to
only increase the embitterment

of discord.
Meanwhile there
new controversies, which
and develop other elements

develop,
in
one
way
or
another, petty misdemeanors which, in their minds, soon

grow to be occurrences of the gravest import. Thus, then,
it fairly
rains complaints
and counter complaints
of insults,
damages, warrants, examination of witnesses,

trials, legal expenses, attachments without number, so that
patients are constantly busy in one court or another. Their
claims for
means
of natural livelihood
become more and more depleted.
In addition to their vexations and constant excitement the
demands of a livelihood come in to increase the irritability

and embitterment of the patients.
The development of this condition of affairs may require
ten years or more. There is progress in the disease only in
so far as the relations of the patients to their environment
gradually become more and more strained. They not only
an unfair
neighbors and
upon every occasion they are treated
feel
that
and
hostile
in
manner, but they also think their

acquaintances are angry and retaliating. Thus, there are
continuous warfares which, because of their contrary dispositions, are being constantly incited
but they never go as far as to
by every little incident,

form true delusions. The
patients regard their opponents, without exception, as blockheads, trash, and scoundrels. They are not always at strife
with the same persons, sometimes this one and sometimes

that one, although the hostility toward certain ones may be
held for
many
years.
The same occasion does not always
534
serve as the starting-point for all the controversies that arise

later, but there are numerous individual occurrences, which
are not necessarily related, although they may have all
In
arisen from the same source of personal animosity.
other words they lack the subjective bonds which unite and
draw together all the individual experiences into a continu-
ous chain.
The pseudoquerulants are distinguished from
Diagnosis.
the genuine querulants by the absence of genuine delusion

formation. The controversies of querulants arise only from
an endeavor to obtain expiation for an injustice originally
inflicted
on them, and which appears to them as the out-
come of hostile persecution. This is the reason why they

are dissatisfied with the court's verdict, regard later failures
as a further continuance of that persecution, and resort to
the most desperate measures in order to win. In pseudo-
querulants there
usually give
rarely
doubt the
to regard
them.
nothing of this kind. The patients

see they can obtain nothing more,
impartiality of the courts, and come
is
up when they
them
They
as accomplices of their enemies and slander

forget the old quarrels, or at least do not revive
them, and are not always striving to renew investigations.

The circle of their enemies also becomes enlarged as a result
some particular personal friction, which, however, has no

delusional connection with the central point of their struggle.
Not infrequently the rights of the pseudoquerulants are
of
maintained by the courts on
many
points.
This also
indication that their contact with the courts
is
is
an
not influ-
enced by uniform delusions. Patients are usually much

the worse for their incessant conflicts; they by no means
carry them out with the grim satisfaction which is afforded
the querulants in the fulfilment of their delusional tasks.
On the other hand, they are sometimes rather unhappy
535
because of their everlasting troubles. Occasionally the removal of the chief source of trouble by some change in the
manner of living may produce a marked improvement, if

some other occasion does not arise to create new difficulties.
As the patients grow older they become dull and
indifferent, but on the other hand they are often stubborn.
Pseudoquerulants never develop later into true querulants.
One seems
justified in spite of their external similarities in
maintaining that they represent totally different conditions.

Pseudoquerulancy is a form of constitutional endowment
which
exists
from youth up and continues without
essential
change, while in true querulancy we have a disease process

which begins at a definite time and runs its regular course.
There is a sharp line between psychopathic pseudoquerulants
and the ordinary manifestations

irritable, litigious, and obstinate.
Treatment.
There
is
little
of those persons
opportunity for
who
are
efficient
treatment of the pseudoquerulant. A temporary residence

in an institution, or a change to an environment which is
from the former difficulties, may be an advantage. In

way the removal of the chief source of trouble or
the friendly intervention of trusted persons is helpful. Patients do not do well without some restraint of their liberty.
free
the same
XV. DEFECTIVE MENTAL DEVELOPMENT

UNDER
this
heading are described those mental states
which are the result of an incomplete or early interrupted

development of mental life. As distinguished from the promental deterioration, these states may be regarded
retarded mental development. It not
infrequently happens that both conditions exist in the
cess of
as conditions of
same individuals, as when a deterioration psychosis develops

in an individual with defective development.
A defective hereditary endowment is almost always
present. The pathological basis for defective mental develthe incomplete development of the cerebral cortex.
This is often due to some disease occurring during fetal or
infantile life which has an injurious influence upon the devel-
opment
is
oping nervous elements.
Our knowledge
of the anatomical
as yet so incomplete that it is impossible, on a pathological basis, to differentiate between the different grades
facts
is
of defective mental development.
In a general way the
lighter forms are designated imbecility, and the severer

idiocy.
A. IMBECILITY
This form of defective mental development is characterized

by a moderate degree of mental incapacity which is usually
of equal prominence on all sides of the mental life.
Clinically
imbeciles may be divided into two groups, the stupid and the
active y according to the degree of mental activity.
The fundamental symptoms

536
in the stupid
form are obtuse-
DEFECTIVE MENTAL DEVELOPMENT

ness
and
stupidity.
There
is
and
an
537
inability to receive
many
the experiences of life;

consequently the knowledge of the outside world confines
itself to the immediate surroundings, while events without
impressions, or to grasp
utilize
the patients' narrow mental horizon pass unnoticed. Probably the sensory presentations are retained, but there is an
absence of an elaboration of individual experiences into general ideas.

The individual and insignificant elements make
up the fund
relations and
of experience.
Essential
and fundamental
distinctions are not recognized.

Thought
limited
to
scanty,
mostly
daily experiences, usually travels
the same path, and, according to the research of Buccola,
is
is
really retarded.
Judgment
is
defective
and uncertain, and often determined
by chance ideas not the outcome of past experience.
Pa-
tients also fail to consider the possible consequences of their
actions, either in reference to themselves or others.
Memory
accurate only for the most prominent events of life. Yet

sometimes trifling incidents are firmly retained, while the
more essential are forgotten. The narration of events, as
is
remembered by them, is noticeably faulty because of numerous omissions and changes. The same events narrated
at different times show many contradictions, though sometimes they may be repeated parrot-like. Consciousness
The patients recognize the surroundings and
is unclouded.
comprehend questions.
They have no
insight into their
mental condition, but usually regard themselves as perfectly sound.
In the patients' actions and conversations their own per-
always comes into prominence. The central point

about which the whole life revolves is their own physical
sonality
eating and drinking and the possession of

while all else is indifferent.
Occasionally
things desired,
well-being,
538
show the natural
and relaThe superficial sorrow at the loss of some relative

tives.
is quickly lost in the pomp of the funeral procession and the
joy over a new suit of mourning. The absence of sympathy
for those who are in want and unfortunate may explain
they
fail
to
affection for parents
the cruelty which they sometimes display toward animals
and
in their
combats with others.
In emotional
attitude these patients are indifferent, apaat

times
thetic,
shy and anxious, but more often displaying a
Occasionally patients exhibit
simple, childish happiness.
sudden outbreaks of passion, especially if irritated or if they

In conduct they are usually
believe themselves misused.
harmless and tractable, but under evil influences they become
ill-humored, sometimes stubborn and peevish. The sexual
impulses often remain wholly undeveloped, or they are perverted. Attempts to rape, especially children and even
Patients are incapable
animals, are sometimes observed.
of independent activity, yet they are able to do things under
An
supervision.
nical ability,
occasional patient shows a striking techof music or a certain knack
some knowledge
in drawing,
but even this knowledge does not aid them in
producing valuable work.

Lighter grades of this type of imbecility often fail of recognition because of the absence of sharp border lines between
them and the

viduals.
stupidity sometimes present in normal indiImbecilic defects, however, become more and
more apparent as the individual advances in age and is

compelled to take up some responsibility in life. Yet these
may not be recognized, because of the patients'

to
utilize a certain amount of experience and to
ability
engage regularly in a simple occupation. But just as soon
defects
as anything extraordinary occurs,

a mental shock or a
temptation which demands discretion and decision of action,
539
-the mental and moral incapacity becomes evident. Unfortunately at this time their actions are judged from a legal
and not from a medical standpoint. Rigid military discipline brings to the light many such cases, especially in those
countries where military service is required. It becomes
most apparent in stubbornness, insubordination, desertion,

and attacks upon officers. Lack of judgment in handling
these cases sometimes results in suicidal attempts.
Imbecility is usually recognized at an early date.
infancy
it
may
In
be noticed that patients are tardy in learning
how
to laugh, to imitate, and to speak.

Later, at school,
in
are
are
backward
studies,
sluggish, indolent, show
they
poverty of thought and inability to comprehend, and soon
become the sport
of their playmates.
They
find difficulty
and reckon, and the few facts in

or
which
are committed to memory
grammar
geography
are soon forgotten, since they are not essential to their
in learning to read, write,
limited experiences of
life.
fairly
good memory may con-
ceal their incapacity for a long time.
patients are very often refractory, hard to train, and

have a tendency to develop bad traits, such as stealing,
The
annoying dumb animals, and indulging in sexual improprieties, which often necessitates their commitment to indus-
During youth and puberty their mental incapacity becomes still more evident, because of the marked
contrast to the rapid mental development of their playmates. At this time their own development comes to a
trial schools.
may even retrograde, presenting resemblances

to the progressive deterioration of dementia prsecox.
In the active or energetic type of imbecility there is a
morbid activity of the attention and imagination, in contrast to
standstill or
the general sluggishness of the stupid form. Patients are

attracted by every new impression, and unable to direct their
540
attention permanently to any one object; hence their observations are hasty and superficial. They are always ready
judgment without deliberation. This susceptibility

and accidental impressions renders their view of
the outside world very incomplete and fragmentary.
Such
vague pictures lead to faulty conceptions and form the basis
to pass
to new
incorrect judgment.
Circumstances existing only in
their imagination are of far more importance in their defor
liberations
than absolute
unsteady and shows
facts.
Thought, therefore, becomes
many inconsistencies;
patients vacillate
from day to day, draw inconsistent conclusions

from the same premises, and thus their views of life and the
in their plans
outer world lack reality.

Their flighty conversation contains a frequent repetition
of certain high-sounding
often have
little
remarks and commonplaces which
bearing upon the sense.
They
are very
apt to lose the thread of conversation, refer to the most

diverse subjects, but usually finish with some very striking
remark. Such a bombastic style very often conceals from
the inexperienced the actual mental enfeeblement, and leads
to their being regarded as unusually bright individuals.
It is quite in accord
with these mental peculiarities that
patients not only embellish
with
many
fanciful ideas,
and
distort their recollections
but also fabricate extensively.
In spite of evident contradictions in their statements they

reassert them tenaciously and refuse further discussion. Accusations of the patients against relatives and fellow-patients
should, therefore, be accepted with the greatest caution.
These energetic patients possess a better memory than the

apathetic, are able to acquire some new knowledge, and to
adapt themselves to new environment to a certain extent.
The
emotional attitude presents a mobility equal to that

encountered in the attention and the imagination. Every
541
impression is accompanied by an accentuated but rapidly

vanishing tone of feeling, and the moods vacillate from one
extreme to another, showing despondency and exuberance,

despair and enthusiasm, which appear upon little provoViolent likes and dislikes change from day to day;
cation.
the dearest blessed doctor of to-day becomes the vilest scounWhile extravagant in their emotional exdrel to-morrow.
pressions,
with a tendency to emotional outbursts, they
are readily diverted and pacified. Irritability and sensitiveness are always present to a greater or less degree, especially
when
patients believe themselves interfered with; often

they are docile and good-natured. An exaggerated feeling
of self-importance regularly accompanies this form, some
patients even believing themselves specially endowed and
often boasting of their prospects, while at the same time
showing a lack of insight into their diseased condition.
Any
shortcomings on their part are explained by the hos-
tility of relatives
or lack of support.
In conduct the patients are odd, freakish, sometimes

loquacious, forward, pretentious, and silly; sometimes quiet,
and
docile,
reticent.
They
are apt to dress in a peculiar
or to be slovenly in appearance. They work with

varying zeal. In youth they are frequently considered
bright, especially by the parents, but later become fickle,
manner
unable to employ themselves at

aimlessly about, drink,
Many
all,
and indulge
leave home,
wander
in all sorts of excesses.
prostitutes belong to this class.
In
many
of these
cases, where there seems to be only a light grade of imbecility,

there may be some question whether we are not really dealing
with conditions of degeneracy, but the presence of profound

mental deficiency, in spite of a certain amount of supershould leave no doubt. Gudden designated
"
such patients as high-grade imbeciles."
ficial activity,
542
Imbecility
may form the basis for the development of other
psychoses; as, manic-depressive insanity, the psychoses of

involution and dementia prsecox, the last of which in seven
per cent, of cases appears on an imbecile basis. Furthermore,

it often happens that imbeciles present at times some of the
symptoms characteristic of other psychoses; such as, periods
of excitement
and
depression,
not of the manic-depressive
single transitory expansive or persecutory delusions,

type,
occasional hallucinations, and especially the attacks characteristic
the
of
constitutional
psychopathic states. Signs

found in anomalies of the
of physical degeneration are often

skull,
malformation of the palate, misshapen
ears, puerile
expression, chorea, etc.

Course.
The course
of imbecility is quite uniform;

in their attempts to enter a
unsuccessful
patients,
profession or to become employed in mechanical arts, engage
some
in simple labor,
the family.
and
failing in this,
they become a burden to
not infrequent for them to develop some

forms of the insanity of degeneracy,
life,
It is
psychosis later in
manic-depressive insanity, and senile dementia Others show

irregular periods of excitement, with aggressiveness, great
.
irritability,
symptoms
and variable emotional moods. Also, the various

of epilepsy not infrequently develop, which may
also lead to further dementia.
In some of these cases the
dementia predominate, and in others the

epileptic attacks.
Usually it becomes necessary at some
time during their life to confine them in almshouses or hos-
signs of epileptic
pitals for the insane.
Diagnosis.
which are
There are some cases of dementia prcecox

from the lighter active
difficult to differentiate
forms of imbecility. The character of the onset, dating from

childhood, the absence of hallucinations and pronounced
delusions, and of any evidence of earlier acquired knowl-

edge, speak for imbecility.
cox patients
543
Furthermore, in dementia
may show some
prae-
improvement, while imbeciles
present no change.
There are a few cases of hysteria with a moderate degree
of deterioration which might be confounded with imbecility,
but in them the course of the disease is not as uniform and

the mental weakness is not as evident on all sides of the
while in imbecility but few patients present
There are all possible transition stages
hysterical symptoms.
between imbecility and the normal state, among which
psychical
life;
should be classed those weakminded individuals
who
are
overcredulous and superficial in knowledge, getting a smattering
of
everything,
who take hold
but knowing nothing thoroughly,

new with enthusiasm, are easily
of everything
led astray and indulge in excesses, and who are always in

doubt as to their real motives for action.
Treatment.
The treatment
consists principally in providing
of
congenital
imbecility
an appropriate education,
with a view to developing any capacity that may exist.

This is best accomplished in the hands of some competent
tutor or in a private or state institution established for that
The training should by no means be directed

toward
mental education, but should include manual
simply
The use of alcohol should be strenuously avoided.
training.
The removal of adenoids, if present, even though they may
purpose.
not appear to impair the health of the child,

essential.
all
diseases of eyes
and
is
highly
ears should
Furthermore,
be corrected. If, in spite of training, the patients develop
dangerous tendencies, hospital care
is
necessary.
544
B. IDIOCY 1
Idiocy is characterized by a more profound degree of

mental incapacity than imbecility.
2
one of the most imporIdiocy may be regarded as the final
Defective heredity
Etiology.
tant etiological factors.
is
stage of hereditary degeneration.

tive heredity in
Wildermuth
finds defec-
seventy per cent, of cases, mostly in the form
of alcoholism in the parents.

Possibly, also, intoxication of
one or both parents at the time of copulation predisposes
to idiocy.
Severe
illness or
mental shock during pregnancy

(Piper) have been
and hereditary tendency to tuberculosis

noted as causes.
Injuries at the time of birth, prolonged

but
asphyxia,
especially compression by narrow pelves or
In idiocy developforceps are probably important factors.
ing after birth (one-fourth to one-third of cases) the most

typhoid fever,
important causes are infectious diseases,
measles, scarlet fever,
congenital syphilis,
and
and diphtheria;
also
head
injuries,
rachitis.
no longer
regarded as a cause of idiocy, but rather as an accompaniment, recent investigation showing that the growth of the
calvarium is determined by the proportional growth of the
brain and not vice versa. Malformation of the cranium
Premature
ossification of the cranial sutures is
occurs in at least one-half of the cases, in which anomaly
macrocephaly is far more prominent than microcephaly.

extreme grade of the former of these conditions is repre-
An
Emminghaus, Die psychischen Storungen des Kindesalters, 243 f.

J. Voisin,
Sollier, Der Idiot und der Imbecille, deutsch von Brie, 1891
1
L'idiotie,
1901
1893
Pellizzi, Studii clinici
ed anatomo-patologici sulF
Bourne ville, Recherches cliniques et the"rapeutiques sur
idiozia,
1'epilepsie,
rhyste*rie et 1'idiotie (Regelmassige Jahresberichte iiber die Idiotenabtei-
lung des Bicetre).

2
Piper, Zur Aetiologie der Idiotic, 1893.
545
sented by Plate 10, Figure 1, while Figure 2 represents the

condition of microcephaly. Furthermore, the early closure
of the suture has nothing to do with the malformation of the
Narrowness of the base of the cranium accompanies

more often the profoundly stupid forms of idiocy, and smallMore than one-half
ness of the vertex the excited forms.
brain.
of idiots are first-born,
and four to
five
per cent, are twins.
The male sex predominates.

Some cases present
Pathology.
1
defective development of
the central nervous system, either smallness or increased size
of the entire encephalon or malformation of some of its parts;
absence of corpus callosum, of cerebellum, inequality of

hemispheres, sparsity or anomalies of convolutions, and
microgyri, which conditions represent cessation of development, or a reversion to structures characteristic of lower
animals.
In
many
cases
evidences
of
genuine
disease
processes are found, particularly encephalitis, meningitis,

hydrocephaly, and tumor formation, causing extensive
destruction of the cortex (porencephaly) or a general atrophy.

Similar conditions may be due to vascular changes, of which
the most important are endarteritis, thrombosis, and em-
bolism; also occlusion of vessels caused by traumatic hemorrhage at the time of birth or later. Syphilitic disease, either
meningo-encephalitis or endo-arteritis, may lead to idiocy.
Pupillary disturbances in idiocy are usually associated with
syphilis.
Bourneville has described a series of cases of
Hammarberg, Studien und Klinik und Pathologic der Idiotie, Deutsch

von W. Berger, 1895; Pfleger und Pilcz in Obersteiner's Arbeiten,
1
Heft V, 1897; Pilcz, Jahrb. f. Psy., XVIII, 526; Mingazzini, Monatsschr.

f.Psy., VII, 429; Kotschetkowa, Archiv f. Psy., XXXIV, 39; Koppen,
Archiv f. Psy.,
896; Konig, Deutsche Zeitschr. f. Nervenheil-
XXX,
Anton, Handbuch der patholog., Anatomic des

Nervensystems von Flatau-Jacobsohn-Minor, 416, 1904; Weber, Ibid.,
kunde,
1440.
1897,
XI;
546
tuberous hypertrophic sclerosis, which are characterized

by an excessive tumorlike development of glia following an
extensive destruction of the cortical tissues.
The amaurotic family idiocy described by Sachs and Tay

occurs almost exclusively among Jews. The disease develops
during the first two or three years of life in healthy children,
accompanied by general paralysis and atrophy of the optic
nerve, and always terminates fatally in a few months or
While the real nature of the disease is still unknown,
years.
it is probably not due to arrested development, but to an
is
extensive disease process.

Microscopically we may find either an insufficient development of the neurones or evidences of former disease processes.
cells
do not develop beyond
an embryonic stage (Hammarberg).
The cortex is much

and they stand
In underdevelopment the nerve

thinner, the
number
of cells is reduced,
closer together in regular rows with much less gray matter bedifferent layers cannot be clearly dis-
tween them, so that the
tinguished (a characteristic of lower animals). The cells

themselves are embryonic in structure, being mostly of the
same
size
and globular
velopment may
in form.
The degree
of underde-
vary in different parts of the cortex.
Figure 1, Plate 5.)

In other cases there
(See
may be normal
development, with the

usual number and arrangement of cells, but in areas the
cells have entirely disappeared, as the result of a disease
process,
and the
glia
has increased.
In the few cases of
hypertrophic sclerosis, the increase in the size of the brain

is due to the great increase of glia, either as an accom-
paniment or as a result of a degenerative process in the

The nature of the causes which produce such
cortex.
lesions in fetal and early life is still unknown.
They may
be due to intoxication or infection.
Fig.
1.
Macrocephaly.
Fig.
Figs. 3
and
4.
Fig.
3.
2.
Microcephaly.
Fig. 4.
Representing asymmetries of cranium and face.
PLATE
12

Symptomatology.
The symptoms of the
547
disease are best
considered in two groups, the severe and the light forms.

The symptoms of the former correspond to the mental state
presented by an infant during the first days following birth,
while the symptoms of the latter correspond to the mental
states of later infancy.
In the severe cases of idiocy patients are wholly unable
comprehend external impressions, to gather experience,

or become acquainted with the environment, to form clear
ideas or judgments, and indeed they do not possess self-consciousness.
The emotional life is limited to mere fluctuato
tions of the general feelings.
Consequently the impulses

arising from these feelings lead only to simple actions, such
as the taking of food. The patients have no choice of food
and eat anything placed before them, even to pieces of clothing and rubbish. Idiots are not excitable; they show very
little, if any, fear or pleasure, at the most manifesting some
pleasure in kicking or swaying movements while hunger or
physical pain may be expressed in monotonous or shrill
If repeatedly pricked in the same place, causing them
cries.
;
to cry out with pain, they do not try to protect themselves.

Some even pound themselves and inflict severe wounds,
but immediately repeat the
act.
One
girl
would impul-
sively bite deeply into the flesh of her arm, unless pre-
vented.
is delayed, and the whole physical development
The countenance is usually stupid and vacuous.
The movements are clumsy and awkward; patients do not
walk until late, and some never even learn to stand, but are
absolutely helpless. Some restlessness may develop, with a
tendency to move aimlessly about, to sway the head or body
back and forth rhythmically for a long time, to clap the
Teething
retarded.
hands, or to grunt.
Convulsive attacks are of frequent
548
occurrence.
These patients are so utterly helpless that
without constant attention they would quickly perish.

In thelight cases it is possible to fix the attention momentarily
by the aid of some
themA few clear
striking object, but the patients
selves are quite unable to direct the attention.
may enter consciousness, and a limited

number of ideas may be formed, which are extremely simple,
always incomplete, and without connection. Memory is
sensory impressions
very poor ; there
is
no
ability to
make a
selection
from
dif-
ferent impressions in order to establish a basis for the formation of concepts; indeed, a psychic personality is never
developed. Speech, and therefore intercourse with the
Unable to form sentences, idiots present a mixture of incomplete words or

They
syllables similar to the early efforts of an infant.
do not imitate, play, or busy themselves, and are very susenvironment,
is
poorly developed.
ceptible to fatigue.
The lower sensory or selfish feelings dominate the emoand liberate only those impulses for action
tional attitude,
which gratify momentary pleasure. Idiots never feel attracted toward any special individual, never express gratitude, nor
show
grief.
When
irritated
by rough treatment
or opposed, they may show sudden outbursts of rage, attempting to destroy something or to injure some one.
Sexual desires may either remain undeveloped or appear
early
and lead to
reckless masturbation
Often the appetite for food
is
and sexual
assaults.
abnormally developed, pa-
and feeding themselves with their

hands. A few show some one-sided capabilities, such as a
good memory for numbers or words or some very simple
tients eating ravenously
technical
In the
skill.
Many idiots
lighter grades of
are fond of music.
two types may be disand the excited or active,
idiocy
tinguished, the stupid or anergic,

depending upon the distractibility of the attention.
549
The
anergic patients are torpid, thought is sluggish and very

limited, and there is pronounced emotional indifference.
In the active patients the attention wanders aimlessly,

filling consciousness with a variegated, incoherent jumble.
The emotions change rapidly. At one time patients are
show purposeless activity, running

about, laughing, crying, and clapping the hands. Between
these two groups there are numerous transition stages.
stubborn, at another
In idiocy transitory periods of excitement or depression

may occur which present some similarity to epileptic excitement, attacks of manic-depressive insanity, and the excitement which occurs in the end stages of dementia prsecox.
Compulsive ideas, morbid impulses, periods of anxiety, sometimes with suicidal tendencies, may appear, and occasionally
there
may
be simple, childish, expansive, or persecutor^
ideas.
Physical Symptoms.
physical development;
dwarfish.
Countenance
There
is
a stunting of the whole

is undersized or even
the stature
is
from the face and pubes.
childish.
Hair
is
often absent
The
genitals are undeveloped;

menstruation absent, late, or irregular. Teeth are late in
developing and often faulty in arrangement, and the palate
The special senses, especially

usually asymmetrical.
In
are
blunted.
hearing,
eighty per cent, of cases the socalled stigmata of degeneration are present (Wildermuth),
is
malformation of the eyes,

pecially the bones of the face.
viz.
mouth, nose, and esOther frequent symptoms
ears,
are increase or loss of the reflexes, incoordination of the

lower extremities and of the eye muscles, and difficulty of
speech, with elision of the end syllables, stuttering, halting,
and faulty articulation of some or most of the consonants.
All idiots are
awkward and
often
show associated move-
550
ments.
Mirror- writing
Evidences
of
is
found, especially
lesions are
cerebral
focal
among
the
girls.
manifested by
hemiplegia, paresis, contractures, convulsions, choreic and

athetoid movements, aphasia, and in thirty per cent, of the
cases, especially in boys, epilepsy
Diagnosis.
The
recognition
(Wildermuth).
of the
disease,
which
is
only in infancy and in very early childhood, depends

the
insensibility of the children to external influences.
upon
They do not manifest a feeling of hunger, even when lying
difficult
upon the breast or at the approach of the mother, are not

attentive, do not smile or cry, and may be continually
restless; many give evidence of some cerebral disturbance,
as paralysis or hemiplegia. The limbs may remain in a
fetal condition; they do not learn how to walk or talk, and
are unable to understand speech.
Prognosis.
The prognosis
is
unfavorable.
While
idiots
can never reach the rank of normal men, the question of

how much they can develop is of great importance. In
general
it
can be said that
if
their attention can be held
some time, and they give evidence of memory, i.e.

recognize articles and resist what they have once experienced
as disagreeable and appear to understand speech, the
prognosis is more favorable. The appearance of epilepsy
for
in early childhood is very unfavorable.

idiots often lose
quired,
what
little
During puberty
knowledge they may have ac-
and some even present the hebephrenic or catatonic
picture of dementia prsecox. Their life is usually short,

because of their lessened powers of resistance to intercurrent
diseases.
Treatment.
parents should be encouraged as an important prophylactic measure. The con-
Temperance
in
faulty nutrition, which is frequently present,

improves with the relief of insomnia, the prevention of
dition
of
551
masturbation, removal of sources of focal irritation, and

cleanliness.
Epileptic attacks should be combated
strict
with bromids, atropin, or other suitable measures, with

the
profound deterioration. Craniectomy in some cases of microcephaly is an irrational procedure and is fast disappearing from practice.
hope
of
preventing
Besides treatment of the physical condition, the patients

should receive training in institutions for the feeble-minded.
Idiots left to themselves or in a poor environment rapidly
go to the bad. Harmless patients in the care of sisters or
brothers
may become threatening or aggressive and
sexual assaults.
attempt
Such patients are somewhat susceptible
a greater amount
and patience, and more experience than can be
obtained in the ordinary home. An effort should first be
to training.
of kindliness
made
This, however, requires
to teach
employ
them
to walk
and use
their hands, also to
their different senses, to direct their attention
and
to speak, followed by special instruction in the perception

of objects, in distinguishing them, and in forming simple
As a
result of
such training,
many patients
yearly leave institutions well enough trained to be of use in ,a
limited field. They, however, continue to need some care
judgments.
and supervision throughout life, as their inability to get

along in the world and to utilize knowledge stands in striking
disproportion to knowledge taught them.
INDEX
Amaurotic family idiocy, 546.
Amentia, 136, 141.
Acquired neurasthenia, 146.

course, 153.
diagnosis, 153; from congenital neurasthenia, 155.

from dementia paralytica, 153, 315.
from hebephrenia, 266.
from manic-depressive insanity, 417.
etiology, 146.
physical symptoms, 150.
prognosis, 155.
symptomatology, 148.
treatment, 156.
Activity, 78.
(See pressure of activity.)
course, 143.
diagnosis, 144
139.
from collapse delirium,
etiology, 141.
physical condition, 143.

prognosis, 145.
treatment, 145.
Anxiety, hi melancholia, 354.
Aphasia, in paresis, 294.
Apprehension, disturbances of, 16, 104;
in manic depressive insanity, 382.
Arrested paresis, 318.
Acts, compulsive, 90.

impulsive, 90 ; in catatonia, 248.
Acute alcoholic hallucinosis, 171, 189.
course, 193.
diagnosis, 193.
Arteriosclerotic insanity, 333.

from melancholia, 360.
diagnosis, 338
from paresis, 338.
from senile dementia, 379.
pathological anatomy, 334.
severe progressive form of, 337.
;
etiology, 189.
physical condition, 192.
prognosis, 194.
treatment, 194.
Acute cell alteration, 282.

Acute confusional insanity,
from dementia prsecox, 267.
141.
(See
amentia.)
Agitation, in dementia praecox, 258.
in depressed paretics, 312.
in melancholia, 355, 357.
Agoraphobia, 503.
Agostini, 437.
Alcoholic hallucinatory dementia, 171,
195.
course, 196.
treatment, 341.
Articulation, disturbances of, 294.
Aschaffenburg, 125, 524.
Associations, external, 31.
internal, 31.
predicative, 31.
Ataxia, in delirium tremens, 180.

in paresis, 295.
Atropin delirium, 160.

Attacks, apoplectiform, 229; in paresis,
292.
epileptiform, 201, 229; in paresis, 291.
epileptoid, in chronic alcoholism, 168;
in delirium tremens, 180.
paralytic, 291.
diagnosis, 197.
Alcoholic paranoia, 171, 195, 197.
course, 199.
diagnosis, 199.
Attention, 18.
active, 18.
aimless, 18.
treatment, 200.
Alcoholic paresis, 171, 200.
Alcoholism, 162.
blocking
blunting
acute, 162.
chronic, 165.
(See chronic alcoholism.)
in dementia paralytica, 279.
Alcohol pseudoparesis, 171, 201.
Alzheimer, 137, 241, 370.
653
of, 20.
of, 19.
distractibility of, 21.

disturbances of, 18.
in amentia, 142.
in collapse delirium, 138.
in delirium tremens, 177.
passive, 18.
INDEX
554
Attention (Continued)
Cerebral tumor (Continued)

treatment, 343.
Cerebropathia psychica toxamica, 134.
Cerebrospinal fluid, 103, 296.
Charcot, 475.
passivity of, 20.

retardation of, 20.
suppression
of, 19.
Automatism, 227, 245.

Babinski
reflex, 296, 441.
Baillarger, 7.
Barrett, 328.
Bechterew, 328.
Befogged states, 15, 465.

determination of, 105.
hysterical with inconsequential speech,
468.
hysterical with silly excitement, 468.
in epileptic insanity, 444.
Blocking of the will, 80.
Blood changes in dementia paralytica,
298.
Bonhoeffer, 172, 173, 184, 189.
Born criminals, 515.
diagnosis, 520.
etiology, 517.
treatment, 521.
Brain abscess, 343.
Bromism, 455.
Busyness, 79, 392.
Cabitto, 437.
Capacity for mental work, disturbances

of, 57.
Childishness, 228.
Chloroform intoxication, 159.
Chorea, acute delirium of, 128.
Huntingdon's, 324.
Chorea Magna, 458.
Chronic alcoholism, 165.
diagnosis, 169.
etiology, 165.
prognosis, 169.
treatment, 169.
Chronic intoxication, 162.
Chronic nervous exhaustion, 146.

acquired neurasthenia.)
(See
Circumstantiality, 36, 385, 438.

Classification of mental diseases, 115.
Cocain hallucinosis, acute, 211.
Collapse delirium, 136, 137.
course, 138.
from acute delirium,
diagnosis, 139;
130.
from epileptic befogged states, 139.

etiology, 137.
prognosis, 139.
Carbonic acid narcosis, 160.
treatment, 139.
Carphologia, 123.
Catalepsy, 83, 247.
Catatonia, 241.
(See dementia praecox,
catatonic form.)
Catatonic excitement, 79, 248; differentiated from amentia, 144; from
collapse delirium, 139 from acute
;
delirium, 130.
Catatonic stupor, 80, 245; differentiated
from post-infection psychoses, 134.
Cells, plasma, 284.
Cells, rod-shaped, 284.
Cell sclerosis, 282.
Cephalalgia, in acquired neurasthenia, 150.
Cerea flexibilitas, 83, 248.
Cerebral apoplexy, symptoms of, 343.
Cerebral hemorrhage, symptoms of, 343.
Cerebral syphilis, 326;
differentiation
from paresis, 318.
Cerebral trauma, 344.
course, 346.
insolation in, 344.
treatment, 347.
Cerebral tumor, 341.
diagnosis, 343 ; from paresis, 318.
Compulsive insanity, 485, 498.

course, 506.
prognosis, 506.
treatment, 506.
Concepts, disturbance of the formation

of, 29.
Conduct
arising
Confusion, 42.
characterized
from a morbid
by
combined form
basis, 95.
flight of ideas, 43.
of, 43.
desultory, 43.
dreamy, 43.
hallucinatory, 43.
stu porous, 43.
Congenital neurasthenia, 146.
Consciousness, clouding of, 14, 50, 105.
clearness of, 15.
double, 59.
Constitutional despondency, 485, 492.
course, 494.
treatment, 494.
Constitutional excitement, 485, 495.
from hypomania, 497.
diagnosis, 497
treatment, 498.
Contrary sexual instincts, 92, 485, 510.
;
INDEX
Contrary sexual instincts (Continued)
course, 513.
diagnosis, 513.
etiology, 510.
prognosis, 514.
treatment, 514.
Constitutional psychopathic states, 470,
485.
Constraint, 243.
Convulsions, 161, 547.
Cortex, gliosis of, 323.
Craniectomy, 551.
Cravings, insatiable, 463.
Criminals, 509.
born, 515.
professional, 519.
Crises, in phobias, 504.
Cretinism, 216.
etiology, 216.
treatment, 218.
15.
Deceitfulness, 486.
Dejection, 70.
with a feeling of weariness of
Delbrueck, 526.
Delinquente nato, 516.
Delire de negation, 353.
Delire du toucher, 504.
Delirium, acute, 129.
diagnosis, 130.
anxious, 447.
conscious, 448.
occupation, 176.
Delirium tremens, 172.
abortive form of, 179.
course, 181.
of
of
of
of
of
persecution, 53, 262, 312, 425.

physical influence, 262.
self-accusation, 53, 311, 350.
self-aggrandizement, 53.
suspicion, 365.
religious, 243.
sexual, 54.
somatic, 54.
systematized, 52, 427.
unsystematized, 52.
Dementia, acute, 136.
simple hypochondriacal, 231.
Dementia paranoides, 257.

tia prspcox,
(See
demen-
paranoid forms.)
Dementia
paralytica, 276.
agitated form, 298, 307.
course, 314.
demented form, 298, 299.
depressed form, 298, 310.
diagnosis, 315; from acquired neurasthenia, 153.

from acute alcoholic hallucinosis,
194.
arteriosclerotic
insanity, 318,
339.
life,
71.
from acute alcoholic
hallucinosis, 193.
from
from
epileptic befogged states, 182.

paresis, 182, 317.
etiology, 172.

prognosis, 182.
treatment, 182.
Delusions, 48.
expansive, 53, 233, 243, 263, 302, 307,
396, 398, 425.
fantastic, 54, 257, 365.
hypochondriacal, 54, 351, 364, 403.
nihilistic, 53, 353.
of infidelity, 198, 365.
of jealousy, 54, 197.
of mental soundness, 55.
Delusions (Continued)
from
Dammerzustand,
diagnosis, 182;
555
(See insight.)
from
from
from
from
from
collapse delirium, 139.

delirium tremens, 182.
dementia prsecox, 266, 270.

Korssakow's psychosis, 188.
melancholia, 360.
etiology, 276.
expansive form, 298, 301.

pathology, 279.
prognosis, 318.
treatment, 319.
Dementia prsecox, 219.

catatonic form, 241.
catatonic form, course, 252.
catatonic form, diagnosis, from amentia,
267.
from epileptic befogged states, 268.
from mania, 269.
from manic stupor, 269.
from paresis, 266.
catatonic form, physical symptoms, 252.
catatonic form, symptomatology, 242.
diagnosis, 265; from acquired neurasthenia, 266.
from acute alcoholic hallucinosis, 194.
from alcoholic hallucinatory dementia,
197.

from paresis, 317.
INDEX
556
Dementia praecox (Continued)
from post infection psychoses, 133.

from presenile delusional insanity,
368.
etiology, 219.
exacerbations
in,
Emotional attitude, 138, 143, 149, 178,
255.
hebephrenic form, 230.

hebephrenic form, course, 237.
hebephrenic form, diagnosis,
acquired neurasthenia, 266.
hebephrenic form, diagnosis,
amentia, 267.
from
from
from imbecility, 272.

hebephrenic form, physical symptoms,
237.
hebephrenic
form, symptomatology,
231.
paranoid forms, 257.

paranoid forms, course, 260.
paranoid forms, physical symptoms,
260.
paranoid forms, symptomatology, 257.

paranoid forms, second group, 260.
paranoid forms, second group, course,
264.
paranoid forms, second group, symptomatology, 261.

pathology, 221.
treatment, 272.
Depression, constitutional, 419.
with a flight of ideas, 410.
Depressive state with flight of ideas
emotional elation, 411.
Derailment of the will, 87.
Desultoriness, 37, 40.
Deterioration, mental, 253.
Dipsomania, 448.
Disorientation, 26, 107.
amnesic, 28, 107.
apathetic, 27, 107.
delusional form of, 28, 107.
Disposition, irritable, 66.
sunny, 67.
Distractibility, 57, 394.
of attention, 21.
Double consciousness, 59.

Dread neurosis, 480.
course, 482.
diagnosis, 482
ity, 482.
Echolalia, 83, 228, 247.

Echopraxia, 83, 228, 247.
Ekmnesia, 59.
Elsholz, 173, 181, 184.
Embolism, 344.
and
196, 204, 225, 235, 244, 252,

260, 264, 289, 300, 305, 309,
366, 372, 375, 377, 379, 386,
398, 401, 429, 440.
Emotional deterioration, 63.
Emotional field, 110.
Emotional irritability, diminution of, 62.
increase of, 62, 110.
Emotions, disturbances of, 62.
morbid, 68.
192,
258,
354,
391,
Energy, specific, 3.
Ennui, 74.
Epidemics, school, 458.
Epilepsy, psychic, 445.
Epileptic befogged states, 444; differentiated from catatonia, 267; from
delirium tremens, 182.
Epileptic furor, 440.
Epileptic insanity, 434.
diagnosis, 450 from paresis, 450.
etiology, 434.
pathology, 436.
prognosis, 451.
treatment, 452.
Epileptic stupor, 446.
Erichsen, 475.
Erythrophobia, 502.
Etat crible, 335.
Examination. (See methods of examina;
tion, 97.)
Excitement, catatonic, 79.

hysterical, 416, 469.
motor, 78.
periodic, 255.
Exhaustion psychoses, 136.

Expression, disturbances
Eye, motor disturbances
of, 93.
of, in
dementia
paralytica, 293.
Fabrications, 25, 185, 233, 287, 339, 372,

375, 377.
Fanaticism, 67.
;
from hysterical insan- Farrar, 126.
from nervousness, 482.

from neurasthenia, 482.
from phobias, 483.
treatment, 483.
Fatigue, 74.
increased susceptibility to, 57, 148, 149,
286, 486.
recovery from, 57.

Fear, 68.
Drunkard's humor, 168.
compulsive, 69.
Dual personality,
in melancholia, 354.
58.
INDEX
Feeling of shame, 76.
Feeling of well-being, 72.
Feelings, 73.
Fe>6, 434.
Fetichism, 92.
Fever delirium, 121.
course, 123.
diagnosis, from delirium tremens, 182.
etiology, 122.
prognosis, 124.
treatment, 124.
(See ideas, flight of.)
Flight of ideas.
Flightiness, 486.
Folie du doute, 501.
Frivolity, morbid, 67.
Fuerstner, 323.
Gabiana, 278.
557
Hoffman, 475.
Homosexuality, 512.
Horrors, touch of, 179.
Humor, drunkard's,
168.
Hunger, 75.
Huntingdon's chorea, 296, 323.
course, 324.
diagnosis, 325.
Hydrophobia, 128.
Hyperprosexia, 22.
Hypersuggestibility, 247, 248.
Hypnotism, '171, 474, 483, 514.
Hypochlorization, 453.
Hypochondriasis, 150, 311, 415.
Hypomania, 390.
Hysterical constitution, 457.
Hysterical insanity, 457.
course, 469.
from catatonia, 470.

from epileptic insanity, 450.
Garbini, 278.
Gianelli, 341.
diagnosis, 470;
Gliarasen, 330, 371.

Gliosis of cortex, 323.
Gowers, 436.
etiology, 458.
Grave alteration, 282.

Graves 's disease, 214.
pathology, 459.
Grtibelsucht, 500.
Gudden, 278, 541.
prognosis, 470.
treatment, 471.
Hysterical lethargy, 467.
Habitual criminals, 524.
Hagen,
7.
Hallucinations, 3, 5, 10, 104, 137, 174,

198, 222, 232, 242, 258, 261,
300, 305, 309, 312, 352, 354,
372, 375, 378, 383, 396, 404,
438.
189,
286,
365,
428,
dermal, 12.
elementary, 4.
microscopic, 13.
muscular, 12.
of general senses, 12.
of
of
of
of
of
hearing, 11.
memory,
25.
sight, 11.
smell, 12.
taste, 12.
psychic,
7.
reflex, 9.
stable, of
Kahlbaum, 4.
Hammarburg, 546.
Hasheesh delirium, 159.
Headache, 290.
Head
injury, 344.
(See dementia praeHebephrenia, 230.

cox, hebephrenic form.)
Hertz, 173.
Hirechl, 165.
Ideas, compulsive, 33, 401.

delusional, 364.
disturbances of the formation of, 29.
fixed, 51.
flight of, 37, 43, 385, 387,
390.
hypochondriacal, 461.
pessimistic, 308.
simple persistent, 34.
store of, 287.
tormenting, 498.
Idiocy, 544.
diagnosis, 550.
etiology, 544.
pathology, 545.
prognosis, 550.
treatment, 550.
Ill-humor, periodical, 443.
Illusions, 3, 5, 10, 104, 137, 174, 372,
apperceptive, 8.
dermal, 12.
muscular, 12.
of general senses, 12.
of sight, 11.
of smell, 12.
of taste, 12.
438
INDEX
558
Imagination, 44, 287, 439.
morbid excitability
Kahlbaum,
Keniston, 441.
of, 30.
simple sluggishness of, 44.

Imbeciles, high grade, 541.
Kleptomania, 92, 508.
Koppen, 346.
Korssakow's psychosis,
Imbecility, 536.
course, 542.
from hysteria,
diagnosis, 542
543
treatment, 543.
Impulsions, 498, 504.
Impulses, 440.
morbid, 91, 508.
course, 509.
from
diagnosis, 509 ;
sanity, 509.
treatment, 509.
Impulsiveness, 488.
of,
treatment, 189.
Kraepelin, 220, 277, 278.
Krafft-Ebing, 510.
Kranisky, 437.
compulsive in-
402.
Indifference, 45.
Infection deliria, 121, 125.

course, 127.
outcome, 127.
treatment, 130.
Infection psychoses, 121.
Influenza, 128.
Influenza insanity, 121.

Insanity, compulsive, 33.
epileptic, 434.
hysterical, 457.
impulsive, 485, 507.
manic-depressive, 381.
myxcedematous, 214.
of degeneracy, 485.
post-epileptic, 445.
pre-epileptic, 444.
querulent, 432.
Insight, 233, 251, 259, 288, 300, 309, 352,
365, 372, 384, 402, 404, 439.
absence of, 55.
Insomnia, 151, 156, 357, 362.

Interference, 84.
Intervals, lucid, 413.
Intoxication psychoses, 159.

Intoxications, 159.
Involution psychoses, 348.
Irabundia Morbosa, 66.

Irritable disposition, 66.
Janet, 482.
Jolly, 182.
Judgment, 47, 108, 224, 235, 288, 366

439.
Jurgens, 328.
Juvenile Paresis, 277.
16, 24, 25, 28, 134,
171, 183.
course, 187.
diagnosis, 188.
etiology, 183.

Impulsive acts, 90.

Impulsive insanity, 485, 507.
Inadequacy, feeling
6, 7, 9, 88.
Kaplan, 328.
Legrand du
Saulle, 448, 501.

Lesions, focal, in dementia paralytica,
284.
vascular, in dementia paralytica, 283.
Liar, morbid, 526.
Lombroso, 516.
Macrocephaly, 544.
Malaria, delirium
of,
127.
Mania, 390, 394.

chronic, 418, 497.
constitutional, 418, 497.
course, 397.
delirious, 390.
course, 399.
grumbling, 408.
irascible, 407.
unproductive, 408.
Manic-depressive insanity, 381.
course, 412.
delusional form, 402.
depressive states, 400.
course, 406.
diagnosis, 415.
from acute alcoholic hallucinosis, 194.
from amentia, 144.
from collapse delirium, 139.
from dementia pracox, 268, 269.
from paresis, 316.
from post infection psychoses, 133,
134.
duration, 413.
etiology, 381.
mania, 390.
manic states, 390.
mixed states, 407.
INDEX
Manic-depressive insanity (Continued)
nature of, 382.
prognosis, 417.
simple retardation, 400.

course, 402.
treatment, 419.
Manies mentales, 498.

Mannerisms, 86, 240, 249, 254.
Marchand, 278.
Marme,
559
Morbid
liar,
67, 526.
diagnosis, 530.
from constitutional excitement, 530.
from the unstable, 530.
prognosis, 531.
treatment, 531.
Morbid personal peculiarities, 415.

Morbid swindlers, 67, 526.
Morbid temperaments, 65.
Morphinism, 202.
205.
Masochism, 92.
Megalomania, 302, 307.
Melancholia, 32, 348.
course, 358.
diagnosis, 358 from acute neurasthenia,
154.
from arteriosclerotic insanity, 360.
from paresis, 315.
from post infection psychoses, 133.
from senile dementia, 360.
;
abstinence
symptoms
in,

prognosis, 206.
treatment, 207.
Morphin intoxication, acute, 203.

chronic, 203.
etiology, 349.
Motor excitement,

prognosis, 360.
smaller group, 352.
treatment, 361.
Multiple sclerosis, 326.

Muscular tension, 85, 246.
Memory,
23, 178, 224, 234, 244, 286, 366,

372, 384, 391, 429, 438.
accuracy of, 25, 106.
fabrications of, 106.
hallucinations of, 25.
impressibility of, 23, 106, 384.
retentiveness of, 23, 24, 106.
retrospective falsifications of, 427.
Mendel, 475.
Menstrual insanity, 255.
Mental elaboration, disturbances of, 23.
Methods of examination, 97.
anamnesis of the disease, 98.
family history, 97.
muscular system, 100.
personal history, 97.
status praesens, 99.
Meyer, A., 328, 344, 346.
Microcephaly, 544.
Moebius, 459.
Moli, 165.
Moll, 510.
Monomania, 51.
Mood, change of, 65.
Moral imbecility, 516, 520.
Moral insanity, 515, 516.
Morbid emotions, 68.
Morbid feelings of pleasure, 71.
Morbid frivolity, 67.
205.
course, 206.
diagnosis, 206.
etiology, 202.
78.
Mutism, 88.
Mysophobia, 503.
Myxcedematous
insanity, 214.
course, 215.
etiology, 214.

treatment, 216.
Nausea, 75.
Negativism, 88, 89, 227, 245, 246.
Neologisms, 250.
Nervous dyspepsia, 152.

Nervousness, 485.
course, 490.
diagnosis, 490
treatment, 491.
;
from neurasthenia, 490.
Nervous weakness, 148.

Neurasthenia.
(See
acquired
neuras-
thenia, 146.)
congenital, 146.
sexual, 488.
Neurocerebrite toxique, 134.

Nissl, 125, 164, 166, 174, 202, 209, 242,
284, 331, 469.
Onomatomania, 499.
Opium smoking,
159.
Oppenheim, 475.
Oppression, feeling of, 354.
Organic dementias, 323.
Pain, 75.
Paralysis of the will, 77.
INDEX
560
Paramimia, 228.
Paramnesia, 25.
Psychoses (Continued)
post-febrile, 121.
Paranoia, 53, 423.
post infection, 131, 188.
course, 430.
diagnosis, 431.
Pyromania, 93, 508.
from dementia prsecox, 271, 431.

erotic, 428.

etiology, 423.
prognosis; 432.
religious, 428.
treatment, 432.
(See dementia paralytica.)
ascending, 295.
Paresis, 276.
arrested, 318.
tabo, 295.
Peculiar individuals, 66.
Perception, 176.
disturbances of, 3, 104.
Reperception,
6, 7.
Resistance, in catatonia, 245.

Rest cure, 361.
Restlessness, 362.
nocturnal, 373.
of attention, 20.
of thought, 385.
Richet, 453.
Rigid tension, 81.
4.
Perplexity, 27.
Perseveration, 35, 107.
Personality, dual, 58.
Petite mal, 346.
Phobias, 69, 498, 502.
Piper, 544.
Sachs, 546.
Sadism, 92.
Sadness, 70.
Santonin, 159.
Schaefer, 296.
Pleasure, morbid feelings of,

Pneumonia delirium, 121.
Schrenk-Notzing, 510.
71.
Porencephaly, 545.
Practice, 57.
differentiated
Presbyophrenia, 16, 375;
from Korssakow's psychosis, 188.

delusional
Presenile
insanity,
364.
367.
diagnosis,
etiology, 364.
prognosis, 368.
treatment, 368.
Pressure of activity, 78, 387, 392.
Pritchard, 515.
Pseudodipsomania, 524.
Pseudohallucinations, 7.
Pseudoquerulants, 531.
diagnosis, 534.
treatment, 535.
Psychic epilepsy, 445.
Psychic hermaphroditism, 512.
Psychic weakness, 50.
Psychogenic neuroses, 457.
Psychomotor retardation,
of, 47.
Reflexes, in dementia paralytica, 296.
in epileptic insanity, 441.
Relapses, in delirium tremens, 181.
Remissions, 301, 307, 310, 314.
in catatonia, 253.
in paresis, 314.
Retardation, 80, 389, 400, 404, 405.
falsifications of, 17.
phantasms,
Reasoning, disturbances
80, 389.
348,
Schules, 87.
Schultze, 475.
Schuster, 342.
Seclusiveness, 66.
Self-accusations, 403.
Self-aggrandizement, 53.
Self-consciousness, 58.
falsification of, 60.
splitting of, 58.
Self-depreciation, 53.
Self-importance, 426.
Senile delirium, 377.
Senile delusional insanity, 378.
Senile dementia, 24, 348, 369.
379
from melancholia, 360
from paresis, 318.
diagnosis,
etiology, 369.
severer grade of, 374.
treatment, 380.
Senile decay, 370.
Senility, 379.
Sensations, false, 383.
Sense of reality, 486.
Psychopathic personalities, 515.

Psychopathic states. (See constitutional
Sensibility,
psychopathic states.)
Psychoses, polneuritis, 134.
17.
Septic states, 128.
INDEX
Sexual
Sexual
Sexual
Sexual
Sexual
Sexual
561
Thought (Continued)
delusions, 54.
excitability, 76.
feelings, 76, 373.
acceleration of, 56.

circumstantiality of, 107.
feelings, perverted, 76.

indifference, 76.
neurasthenia, 488.
confusion
of, 42.
desultoriness of, 107.
(See desul tori-
ness.)
Simple syphilitic dementia, 326, 327.
disturbance of the rapidity
course, 328.
paralysis of, 31, 107.
diagnosis, from arteriosclerotic insanity, 340.
rambling, 38.
retardation of, 32, 56, 107.
train of, 107.
Simulation, 479.
Smallpox, initial delirium

Somatic delusions, 54.
of,
126.
Thrombosis, 344.
Tics, 494.
Somnambulism, 446, 467.
Tobacco, 72.
Speech, 180, 294, 387, 398, 442.
Tormenting
explosive, 294.
hesitating, 294.
inconsequential, 250, 468.
scanning, 294.
slurring, 294.
Spirit possession, 263.
Splitting of consciousness, 58.
Spratling, 434, 437.
States, sad and anxious, 469.
stuporous, 313, 405.
Status epilepticus, 455.
Stereotyped movements, 86.
Stereotypy, 85, 227, 248.
Striimpell, 475.
Stubbornness, 89.
Stupor, catatonic, 80.
manic, 410; differentiated from catatonia, 417.
Subsultus tendinum, 123.
Suggestion, simple, 474.
Suicide, 356, 363.
Sully, 25.
Superfluous embellishment, 87.
(See morbid
Swindlers, morbid, 67.
Toulouse, 453.
swindlers
and
liars.)
Swindlers, 529.
Syphilis, 278.
Syphilitic pseudoparesis, 326, 329.
course, 330.
diagnosis, 331
of, 56.
from
senile dementia,
379.
pathology, 330.
physically, 329.
treatment, 332.
ideas, 498.
Tramps, 529.
Transitions, 414.
Traumatic delirium, 344, 345.
Traumatic dementia, 344, 345.
Traumatic hysteria, 475.
Traumatic insanity, primary, 345.
Traumatic neuroses, 457, 475.
diagnosis, 479.
from constitutional psychopathic
states, 479.
from hysterical insanity, 479.
etiology, 475.
prognosis, 479.
treatment, 480.
Typhoid delirium, 121.
Typhoid initial delirium of, 125.
Ulrichs, 510.
Unconsciousness, 15.
determination of, 105.
Unpleasant, increased susceptibility
the, 65.
Unstable, the, 521.

diagnosis, 525.
from born criminals, 525.

from hysteria, 525.
treatment, 526.
Vasomotor disturbances, 297.

Tabetic psychoses, 332.
Tabo-paresis, 295.
Tay, 546.
Temperature, 252, 297.
Tension, muscular, 85.
rigid, 81.
Thought, 178, 224, 234, 244, 263, 305, 309,

352, 354, 366, 371, 385, 438.
2o
Verbigeration, 95, 251.

Visions, 104.
Voice of conscience, 105.
Voices, internal, 12.
Volitions, 77.
Volitional impulses, crossing of, 85.
diminution of, 77.
facilitated release of, 81.
to
INDEX
562
Volitional impulses (Continued)
release of, 79.
increase of, 78.
impeded
Wanton
Warm
happiness, 72.
bath, prolonged, 140.

Weariness, prolonged, 148.
Weigert, 284.
Well-being, feeling of, 72.
Wernicke, 184.
Westphal, 475.
Wildermuth, 434, 435, 436, 544, 549, 550.
Wilfulness, 463.
Will, blocking of, 80.
diminished susceptibility
of, 88.
distractibility of, 84.
heightened susceptibility of the, 83.

hypersuggestibility of, 83, 227.
paralysis of, 77.
weakness
of, 83.
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CLINICAL PSYCHIATRY

KRAEPELIN'S "LEHRBUCH DEE PS YCHIATRIE "

ROSS DIEFENDORF, M.D.

PSYCHIATRY IN YALE UNIVERSITY

MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, OF THE

THE MACMILLAN COMPANY

COPYRIGHT, 1902, 190T,

THE MACMILLAN COMPANY.

Berwick & Smith Co.

PREFACE TO THE FIRST EDITION

of Kraepelin in psychiatry accessible to American medical

classes in psychiatry in the

of Yale University, but as well for other American

constantly growing number of his disciples, it was the

the Kraepelin psychiatry to our peculiar American

The classification, terminology, and, wherever possible,

traumatic neuroses, also the treatment in epileptic and

and acquired neurasthenia.

PREFACE TO THE FIRST EDITION

The only omissions

are the general etiology, diagnosis,

in the first volume of Kraepelin, but such

The work has been done

as Assistant Physician and Pathologist of the

leave to express in this place his grateful appreciation of

He is particuhospital, especially Dr. Charles W. Page.

PREFACE TO THE SECOND EDITION

favorable reception of the

Psychiatry and its constantly increasing use as a text-book

based on the seventh edition of Kraepelin's "Lehrbuch

compelled to work, while the more elaborate procedure of

psychogenic neuroses and the psychopathic states which

given fuller consideraPersonalities did not

The chapter on Psychopathic

The writer has

appear in Kraepelin's earlier edition.

tions without explicit references occur under the

PREFACE TO THE SECOND EDITION

in the preparation of the first edition, the work has

Physician and Pathologist of the Connecticut

for the Insane,

under special obligations to

for help in reading proof

arrangement of the chapter on Epileptic Insanity, and to

and suggestions with regard to the general

A. Disturbances of the Process of Perception

double thought, apperceptive

illusions, reflex halluci-

illusions of hearing, sight, taste,

attention, retardation of attention, blunting of attention,

Disturbances of Mental Elaboration

Disturbances of memory, disturbances of the impressibility of

Disturbances of the Formation of Ideas and Concepts

External association of ideas, internal association of ideas,

cumstantiality, flight of ideas, rambling thought, desultoriness.

Disturbances of Judgment and Reasoning

systematized delusions, delu-

ment, delusions of mental soundness (absence of insight),

Disturbances of the Emotions

Emotional deterioration, temporary increase of emotional

Increased susceptibility to the unpleasant, apprehensiveness,

Fear, compulsive fears, phobias, dejection, sadness with ex-

citement, morbid feeling of pleasure, wanton happiness,